MEDICARE AUDIT, IS THERE THE WAY OUT?
Some times my clients ask me about Medicare audit,
how it works and what one could expect from it.
The Medicare audits are different from the commercial health insurance audit or state government audit.
And in resent years it's become more difficult to deal with.
There are two types of Medicare audit:
The regular one: when Medicare checks the claims (usually, in small quantities, could be up to 20 claims)
some time after the payment had been made to practitioner. Practitioner has ability to agree or disagree
with requests, dispute decisions, etc.
This kind of audit does not affect the efficiency or functioning of the practice.
The most devastating one is the other one- pre-paid audit. When practitioner receives the letter
with those words- it means the ax is up in the air and pretty soon it will go down really fast.
If you have not experienced this one yourself you would not believe that it might be possible.
Here is quick overview of pre-paid audit.
How it works?
In short: checks are not coming any more.
For how long?
Duration could be from one to four years.
How they could do that to you or to any one, for that matter?
Yes, they do it regularly, even though they should not.
Why?
Because it's their job, they receiving salaries for it, and they have families to feed too.
Now, I could explain the process in details.
After receiving the letter from outsourced auditing organization about Medicare pre-paid
audit you will have approximately two weeks with remaining scheduled payments for your services.
Then, instead of the payments you will start to receive the letters with requests for medical notes.
Of course, you gladly and happily respond on those requests and mail all medical notes at no time.
But then, some how, you will start to receive denials from Medicare contractor with remark codes
explaining that documentation had not been received. Upset, you make copies again and mail them with
certified mail. Well, nothing is coming back. You start to call, to check if notes had been received,
yes, they were but they are in process to been reviewed.
By that time, it is already going on for two months, let's see what will happen next:
You still working your usual hours, paying your expenditures, but getting more and more worrying.
Still, instead of the payments for services, you will continue to receive requests for medical notes
for all your services provided to Medicare patients. Of course, you respond on them. And then,
approximately 4 to 6 months later you will start to receive denials due to lack of medical necessity
for the services provided.
All and any services would be denied.
I am not joking. I saw once denial for the first visit with remark
" no medical necessity" . After that, you are going to realize, that you have to do something,
may be to find good attorney, or may be write the appeals, or letters with demand for explanations,
or something else. You could even go to court. Unfortunately, nothing is working, as far as I see
in my experience with this kind of cases.
You will understand, that for all services you provided, you might never get paid by Medicare.
Depending on percentage of Medicare patient that you treat, you might start to think really serious
about what to do next.
Yes, I understand that there are fraudulent activities in some instances, yes, some individuals are
abusing the system. However, those clients of mine, who went under this kind of audit, honestly
are not deserving that. We work with them, trying to lay out the strategy how to resolve these issues
without significant loss for their medical practice.
And we have some other questions opened:
Health insurance companies collect the premium from the policy holder and compute it
against the payments for the service provided. When the premium is calculated, how many per cents
the will allocate for themselves?
Will they consider the ability of the members to pay monthly fee, the employers portion of the payment,
quality and true cost of the services?
And may be the most important one- will they still provide
health insurance coverage if they know that the premium will not be paid?
how it works and what one could expect from it.
The Medicare audits are different from the commercial health insurance audit or state government audit.
And in resent years it's become more difficult to deal with.
There are two types of Medicare audit:
The regular one: when Medicare checks the claims (usually, in small quantities, could be up to 20 claims)
some time after the payment had been made to practitioner. Practitioner has ability to agree or disagree
with requests, dispute decisions, etc.
This kind of audit does not affect the efficiency or functioning of the practice.
The most devastating one is the other one- pre-paid audit. When practitioner receives the letter
with those words- it means the ax is up in the air and pretty soon it will go down really fast.
If you have not experienced this one yourself you would not believe that it might be possible.
Here is quick overview of pre-paid audit.
How it works?
In short: checks are not coming any more.
For how long?
Duration could be from one to four years.
How they could do that to you or to any one, for that matter?
Yes, they do it regularly, even though they should not.
Why?
Because it's their job, they receiving salaries for it, and they have families to feed too.
Now, I could explain the process in details.
After receiving the letter from outsourced auditing organization about Medicare pre-paid
audit you will have approximately two weeks with remaining scheduled payments for your services.
Then, instead of the payments you will start to receive the letters with requests for medical notes.
Of course, you gladly and happily respond on those requests and mail all medical notes at no time.
But then, some how, you will start to receive denials from Medicare contractor with remark codes
explaining that documentation had not been received. Upset, you make copies again and mail them with
certified mail. Well, nothing is coming back. You start to call, to check if notes had been received,
yes, they were but they are in process to been reviewed.
By that time, it is already going on for two months, let's see what will happen next:
You still working your usual hours, paying your expenditures, but getting more and more worrying.
Still, instead of the payments for services, you will continue to receive requests for medical notes
for all your services provided to Medicare patients. Of course, you respond on them. And then,
approximately 4 to 6 months later you will start to receive denials due to lack of medical necessity
for the services provided.
All and any services would be denied.
I am not joking. I saw once denial for the first visit with remark
" no medical necessity" . After that, you are going to realize, that you have to do something,
may be to find good attorney, or may be write the appeals, or letters with demand for explanations,
or something else. You could even go to court. Unfortunately, nothing is working, as far as I see
in my experience with this kind of cases.
You will understand, that for all services you provided, you might never get paid by Medicare.
Depending on percentage of Medicare patient that you treat, you might start to think really serious
about what to do next.
Yes, I understand that there are fraudulent activities in some instances, yes, some individuals are
abusing the system. However, those clients of mine, who went under this kind of audit, honestly
are not deserving that. We work with them, trying to lay out the strategy how to resolve these issues
without significant loss for their medical practice.
And we have some other questions opened:
Health insurance companies collect the premium from the policy holder and compute it
against the payments for the service provided. When the premium is calculated, how many per cents
the will allocate for themselves?
Will they consider the ability of the members to pay monthly fee, the employers portion of the payment,
quality and true cost of the services?
And may be the most important one- will they still provide
health insurance coverage if they know that the premium will not be paid?
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