Monday, May 5, 2014

How Does Medicare And Its Fiscal Intermediaries Pick Which Doctors And Providers To Audit? CMS Releases Information From 2012 Fee For Service - What Can You Do With This Information?

If you are a Medicare provider (physician or supplier) you will be audited.  The issue is when and why? CMS has recently released some data that Medicare providers and health care lawyers, accountants and consultants should review to understand where they and their clients stand with respect to other providers who bill the same procedure codes for Medicare Part B, fee-for-service (not HMO). 

Do you remember the old Avis car rental ads about "We're No. 2 . . . so pick us because we try harder?" Well, in the Medicare world it is not good to be Number 1, 2 or 3 or anything that is above the bell curve.  If your company or group is, you will be targeted for an audit.  You can provide incredible quality of care, have great records and impeccable credentials but if you are billing higher for your specialty that the norm or are billing more than others in the same zip code, that is a typical ground for an audit.  

How can you tell where you as a provider falls? For calendar year 2012, you can search the Centers for Medicare and Medicaid Services (CMS) database.  CMS claims it released this information “to make our healthcare system more transparent, affordable, and accountable.”  CMS allows you to download the entire file in Excel format. 

CMS has prepared a public data set entitled “theMedicare Provider Utilization and Payment Data: Physician and Other SupplierPublic Use File.” For short, let’s call it “CMS 2012 Physician and Other Supplier PUF.” It contains information on:
(1) utilization;
(2) payment (allowed amount and Medicare payment); and
(3) submitted charges.

It is organized by (a) National Provider Identifier (NPI), (b) Healthcare Common Procedure Coding System (HCPCS) code, and (c) place of service. You can therefore search by codes and zip code to see where you or your client will fall.

The New York Times has taken this same data and created a searchable database aimed at the consumer in an article entitled “How Much Medicare Pays For Your Doctor’s Care?” This means that in a quick glance, anyone can see how much Medicare paid you or your business in 2012. This means employees, competitors, patients, marketers, ex-spouses, and so on.  It also has the provider’s address.  Be prepared for others to discover this information. The NYT also had an article outing some of the physicians who received the largest payments.  Privacy as we used to know it does not exist.  I am still in shock that CMS prepared the information in this way and released this information without respecting some element of financial privacy.

Commentary:  Information is power. Use this to your own advantage and see where you land and understand that if you are high on the curve for your specialty, HCPCS codes or zip code, then you are more likely to be audited or targeted.  You may even have private insurance companies evaluating you once they know your Medicare numbers.  If there are good reasons for your office being higher than the norm, be prepared to demonstrate to Medicare and the carriers the reasons. 

I have been to numerous audits where the auditors frankly told my provider client that they should work on staying under the top of the bell curve in order to avoid future audits. If that will not work for your office, make sure your practice or company is audit ready, documentation is well done and will pass an audit.  Medicare fee-for-service is great for cash flow but it is useless if there will be overpayments and money has to be paid back due to illegible charts, missing procedure notes, evaluation and management notes that do not support the level of service billed even though the time was spent. Auditing does not consider quality of care. It looks at whether the records support the services billed. 

Posted by Tracy Green, Esq.
Green and Associates, Attorneys at Law
Phone: 213-233-2260


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