Health Law | Medicare Contractors
Pennsylvania Health Law Firm
The Martin Law Firm is a Pennsylvania health law firm that represents health care providers throughout the U.S. for Medicare audits and Medicare appeals. Attorney Jason B. Martin is an experienced health care attorney who can analyze your case and assist you in preparing an effective defense to claim denials from Medicare contractors.
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What are Medicare audits?
The Social Security Act establishes guidelines and powers to "promote the integrity of the Medicare program" (42 USC § 1395ddd). This is referred to as the Medicare Integrity Program. In accordance with this mission, the Social Security Act authorizes the Department of Health and Human Services (DHHS) and the Centers for Medicare and Medicaid Services (CMS) to enter into contracts with carriers, fiscal intermediaries and other entities that are generally referred to as "Medicare contractors." Medicare contractors are given the power through the Act to carry out activities including medical reviews, utilization reviews and fraud reviews of providers of health care services.
Contractors often review claims to make the following determinations:
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Coverage Determinations: i.e., whether the service is covered by Medicare or whether the service was reasonable and necessary.
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Coding Determinations: i.e., whether the service was coded correctly pursuant to CPT, CPT assistant, NCD, etc.
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Other Determinations: i.e., whether the claim was priced correctly or whether the claim was a duplicate claim (paid twice).
Who is selected for a Medicare audit?
Medicare contractors often select health care providers for medical reviews when atypical billing patterns are identified or when a suspected problem is identified. A probe review is then conducted, which usually involves an examination by the contractor of 20-40 claims. If the probe review verifies that an error exists, then the severity is classified as minor, moderate or significant. Depending on the severity of the problem, a corrective action plan is usually implemented, which may include the following:
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Education: problems detected at minor, moderate or significant levels will require the Medicare contractor to inform the provider of appropriate billing procedures.
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Medicare Prepayment Review: prepayment review consists of a medical review of a claim prior to payment. The health care provider is often required to submit medical records which are then reviewed to ensure compliance with payment guidelines. Once providers have re-established the practice of billing correctly, the prepayment review is removed.
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Medicare Post-Payment Review: post-payment review involves medical review of a claim after payment has been made. This often means a more serious problem exists, and the provider is faced with a possible overpayment determination and/or recoupment, which will be discussed more thoroughly below.
Medicare Audit or Post-Payment Review Process
Procedurally, the Medicare post-payment review begins with written notice and a request for review of a sample of the health care provider's medical records. The records are reviewed by the Medicare contractor, who then makes a determination whether, for example, the services were medically necessary. The Medicare contractor then gives the provider an explanation of the findings, which usually involves a calculation of the amount that was deemed to be "overpaid" to the provider. Adding to the problem for the health care provider is the ability for the Medicare contractor to extrapolate its adverse findings over the universe of claims to determine the amount of the overpayment. Medicare requires the health care provider to repay this overpayment amount, and CMS has the authority to recoup this amount if the health care provider does not successfully defend his or herself during the appeals process, as explained herein.
Contact an Experienced Health Care Attorney
Medicare contractors often receive a percentage of any amounts collected as their fee for services. As a result, the determinations are often biased, and challenges to these determinations are often successful.
Having an experienced health law attorney is an important decision for health care providers facing an audit from a Medicare contractor. The Martin Law Firm provides exceptional service for its clients, and we would appreciate hearing your case. Contact a health care attorney at The Martin Law Firm for a free case evaluation.
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