Medicare Audit

Data Mining Tools Can Help Identify Possible Problems

(February 8, 2012): While we all know that many Medicare post-payment audits are often generated as a result of sophisticated data mining analyses, the particular elements of concern which may give rise to a specific provider audit are not always so clear. Health care providers interested in compliance can use data mining assessment tools to […]

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Is a RAC Prepayment Review of Your Medicare Claims on the Horizon?

(December 19, 2011): As you know, RACs play an important role in the identification of Part A and Part B overpayments. Since the inception of the RAC Demonstration Project in 2005, RACs have successfully identified a number of improper claims, denying payment for reasons ranging from mere technical errors to broad concerns about medical necessity.

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A CERT Audit Is Serious – Don’t Take These Medicare Reviews Lightly

(November 23, 2011): The “Comprehensive Error Rate Testing” (CERT) program was implemented as a mechanism for the Centers for Medicare and Medicaid Services (CMS) to assess whether their Medicare Administrative Contractors (MACs) are properly paying claims. In other words, is a particular MAC failing to identify and deny improper claims? Alternatively, is the MAC denying

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NCI-Owned AdvanceMed Will Remain the ZPIC Responsible for Zones 2 and 5.

(April 10, 2011): Last week, it was announced that NCI, Inc., one of the nation’s most successful information technology companies had acquired the outstanding capital stock of AdvanceMed Corporation (AdvanceMed), an affiliate of CSC. While the acquisition went largely unnoticed by the health care provider community, the transaction may, in fact, be quite significant. With

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CERT Postpayment Audits: An Overview of the Audit Process

(March 12, 2011): Health care providers around the country are finding their practices and clinics subjected to Medicare post-payment audits by Zone Program Integrity Contractors (ZPICs), Program Safeguard Contractors (PSCs) and Comprehensive Error Rate Testing (CERT) Contractors. While all post-payment audits should be taken seriously, there are real differences between both the contractors and the

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Health Data Insights Begins Medical Necessity Reviews

(August 30, 2010): Health Data Insights (HDI), the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) responsible for auditing health care providers in Region D, has announced it will immediately begin reviews on previously approved projects which involve the medical necessity of selected inpatient DRG payments. A complete list of the medical

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Don’t Take ZPIC Extrapolation Calculations at Face Value

(July 14, 2010): Imagine a Zone Program Integrity Contractor (ZPIC) handing you a claim analysis rife with alleged errors, an indecipherable list of statistical formulae, and an extrapolated recovery demand that will cripple your practice or clinic. What steps should you take to analyze their work? Based on our experience, providers can and should carefully

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Can a ZPIC Extrapolate the Alleged Damages in a Medicare Claims Audit?

(July 12, 2010): Can a ZPIC extrapolate the alleged damages in a case. If the ZPIC’s statistical methodology is properly handled, the extrapolation of alleged damages can be a surefire way of destroying a provider’s practice. We’ve known it for years and yet the government’s passion for statistical sampling only seems to be growing. This

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ACA Reporting and Repayment Mandates are a Real Minefield for Medicare Providers.

(July 9, 2010): Does the failure to promptly return a Medicare overpayment really warrant liability under the False Claims Act (FCA)? Congress thinks so. The Patient Protection and Affordable Care Act (also known as the “Affordable Care Act” or “ACA”) creates an obligation under the FCA whereby a Medicare provider who fails to timely report

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