LAS VEGAS—Do you bill mostly E0260 hospital beds vs. E0250? If so, said Wayne van Halem, president of The van Halem Group, Atlanta, watch out, because that means you could be facing an audit.
“This is a problem because Medicare is an entitlement program. Medicare likes to pay for the least costly alternative,” said van Halem. “The least costly alternative is E0250, so if you are solely billing the E0260, it is likely you are going to be the subject of an audit because they are cracking down on this very strongly.”
Van Halem should know. He’s a former fraud investigator for Medicare.
If your patient doesn’t meet the additional criteria necessary to qualify for a semi-electric bed (the E0260), van Halem said, “you can still provide that but you have to bill it as an upgrade.”
Another caution: Get prepared for more “surprise audits” from the NSC if you operate in Los Angeles, Miami, Dallas, Houston, New York City or Detroit. Those six areas have been designated as “high risk” for Medicare fraud, “so if you are one of the lucky folks who live in those areas, you need to take extra time to be prepared,” van Halem said.
Speaking April 13 at a Medtrade Spring session on coordinating internal and external audits, van Halem and health care attorney Clay Stribling, president of Amarillo, Texas-based HC Comply, stressed that getting prepared for the growing number of Medicare audits is a provider’s best defense. If you aren’t hit with an audit of some type, you will likely be the exception, the audit experts said.
Just check the list of external auditors van Halem ticked off that are now operating on Medicare’s behalf:
- Medical Review, including both pre- and post-pay audits by the DME MACs
- Comprehensive Error Rate Testing (CERT)
- Recovery Audit Contractors
- Benefit Integrity Audits/Investigations (formerly Program Safeguard Contractors, or PSCs, now transitioning to Zone Program Integrity Contractors, or ZPICs)
- HHS’ Office of Audit Services
- National Supplier Clearinghouse, Supplier Audit and Compliance Unit
With the pace of both RAC and ZPIC audits in particular on the increase, the best way to get prepared is to build what Stribling called the “triangle of compliance.”
First, he said, do an internal audit ahead of time to find out your vulnerabilities. “Know your LCDs,” he said, and create an “audit checklist” from looking at the LCD for each of the main products you are providing.
Second, implement corrective action. Third, train your staff. Then six months later, go back and audit again to make sure the corrections and training held, Stribling said.
“Your compliance officer needs to be empowered,” said Stribling, because it takes both time and money to develop an internal audit program. How effective that program is in helping you fend off audits probably depends on “how many hats” your compliance officer/internal audit coordinator wears, he said. If that employee also happens to be your company’s billing manager and safety coordinator, that doesn’t leave much time to focus on internal auditing.
If you don’t think the time and money is worth it, consider van Halem’s comments on the RACs and ZPICs alone.
The RACs, which he termed “Medicare’s bounty hunters” (because they are paid a contingency fee on what they recover), are now moving from automated to complex reviews, which means they will be requesting medical records. In addition, the RACs are now cross-referencing HME claims data with physician claims data to see if it matches up with office visits, etc. Or, for example, “if you have a high percentage of claims coming from one physician,” van Halem said, in the RACs’ eyes that could indicate an inappropriate relationship, and the auditors will look at that.
As for the ZPICs, van Halem said, “These are the most aggressive audits that I’ve seen in the 15 years I’ve been working in this industry.”
It’s not uncommon for providers to be placed on 100 percent prepayment review without notice, he said. “You get 30 days to respond, and it takes them anywhere from 60 to 90 days to process, so you are looking at a minimum of 90 days with no revenue coming in from Medicare.
“This is something you can’t sit and wait to see if it’s going to happen,” van Halem emphasized. “You have to prepare for it.”
