Healthcare Fraud: On the Wanted List
The United States Department of Justice Considers The Following Three The Worst Form of Culprits, not necessarily in that order:
1. Terrorists.
2. Violent Crime Doers.
3. Healthcare Fraud Perpetrators !!!!!!
Now, how and when the medical profession made it to the chart of ignominy is a moot point; but what is certain is that your practice stands a very good chance of hearing from your region’s RAC if the following does not happen in your clinic:
1. At least a couple of audits for every E&M Code that you use.
2. Doing the above at least two times in a year.
3. Getting the above rechecked by at least one outsourced certified coding consultant.
4. Doing at least 5 audits for more frequently used codes like 99213 and 99214.
(If your practice’s code utilization happens to mirror the green and blue lines beware!!!!)
How It All Started And How It’s Going:
a. Despite a 2-year demonstration; the RAC Audit program was officially deemed to be applicable to all states in 2009.
b. At that time Medicare was registering 1.2 billion claims per year or about 10,000 per minute. These numbers have increased in the past couple of years.
c. About 96% of scrutinized dollars involved overpayments or in other words physicians needed to return the money to Medicare.
d. Only 4% involved Medicare paying the physicians some money for underpayment.
e. Medicare has recently approved audits of Level 4 and Level 5 E&M services; because of a 25-40% increase in the usage of the codes in the past decade.
f. Medicare has given approval to extrapolate the audit results; that is if 30% of your charts are analyzed, and out of them around 20% are found to violate the guidelines, that 20% verdict is applicable to the remaining 70% of the charts the auditor will not check.
g. According to a court verdict in Sep 11, 2012, there is no restricted time limit as to when your charts may be pulled and/or when you will penalized. Yes, you will be living under the shadow of an audit all your life!!!! Also, your old records are not safe from an audit!!!
WHY CMS WON’T STOP
If these audits had been lean pickings for the CMS, one could have theorized they would have lost interest in the so-called outlaws. But no, the returns have been substantial. Consider the following figures:
1. CMS had received $4 billion dollars in 2011 in healthcare fraud cases.
2. That was about $7.2 per every $1 invested or a ROI of 720%!!!
3. Thus, they have invested a further $350 million to smoke out the violators!!!
WHAT YOU NEED TO KNOW AND DO
If all of the above is making you feel like a cat on a hot tin roof; don’t fret, there is light at the end of the tunnel. Just keep in mind the following:
1. If you bill Medicare, then you can be certain there will be an RAC Audit, don’t let it take you by surprise.
2. Don’t bill Medicare until you are absolutely sure every service has been properly documented.
3. Don’t jump into the frying pan when an RAC audit request arrives. Remember you have 45 days; use it appropriately to set your records straight (if you haven’t already done it, that is).
4. Don’t let any Tom, Dick, and Harry in your clinic handle this audit request. Ideally it should be given to a dedicated medical coding vendor or medical billing vendor.
5. You have the right to appeal RAC audit verdicts, remember that 1/3rd of these appeals are successful.
6. Or for that matter Medicare denials need to be appealed as well. But sadly only 4% of these are ever disputed, even though nearly 60% of these disputes come out favourably for the providers.
All in All remember that RAC Audits are not Armageddons waiting to happen, but just speed breakers in your clinic’s path, which can be surmounted if you are careful and assimilate the essentials before meeting it head on.
