New Medicare Fraud Audit Update Could Reduce Burden on Compliant Providers Healthcare providers who comply with medical billing requirements will face less Medicare fraud and improper payment audits under a new update from CMS.
www.outsourcestrategies.com
Outsource Strategies International 8596 E. 101st Street, Suite H (800) 670 2809 Tulsa, OK 74133
Medicare covers about 56 million people including those 65 years and older and disabled people of any age. However, this public healthcare program is often subjected to fraud with offenders claiming millions of dollars in Medicare healthcare reimbursement to which they are actually not entitled. Without proper processes in place to detect and prevent fraudulent activities, healthcare providers could face an investigation that may cost them their reputation and revenue. The role of medical billing and coding companies becomes significant at this juncture, as they assist healthcare providers avoid dubious billing practices that could potentially lead to fraud, including Medicare billing fraud. The Centers for Medicare & Medicaid Services (CMS) Medicare fraud and improper payment audit process targets healthcare providers and suppliers who show high medical billing error rates. This process has been updated recently. Medical billing fraud and abuse occurs largely due to medical coding and billing errors which result in improper reimbursements. Fraud is a deliberate deception that results in an unauthorized payment, while abuse is failing to adhere to accepted business practices. As per a recent report from the Health and Human Services Office of Inspector General (OIG), Medicare and Medicaid improper payments exceeded the 10 percent regulatory compliance limit in 2016, and in some cases, were higher than in 2015. Healthcare providers will be under continuous scrutiny and there will be a complete expansion in Medicare recovery audits in 2017. It is important for physicians, practice administrators and medical billing and coding service providers to take proactive steps and prepare for compliance audits. The New TPE Update Advantageous for Compliant Providers CMS recently updated its Medicare fraud and improper payment audit process to target healthcare providers and suppliers who frequently exhibit high medical billing error rates. The new “Targeted Probe and Educate (TPE)” method replaces a medical review strategy that comprised broad medical billing investigations and provider education. It was in 2014 that the Centers for Medicare & Medicaid Services (CMS) first launched a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. This program was named – “Medical review strategy, Probe and Educate”. The results of the program have been rather favorable, leading to a decrease in the total number of claim errors after the providers received education. However, CMS was aware about the fact that this type of review specifically affected providers in home health agencies and those billing under the Two-Midnight rule. As part of its improvement process, the federal agency decided to move from a broad Probe and Educate method to a more targeted approach. As part of the new Targeted Probe and Educate (TPE) program, CMS utilizes Medicare Administrative Contractors (MACs) to focus on specific providers/suppliers within the www.outsourcestrategies.com
(800) 670 2809
service rather than all provider/suppliers billing a particular service. MACs will focus only on those providers/suppliers who have the highest claim error rates or billing practices that vary significantly from their peers. These are identified by the MAC through data analysis. • • •
The new TPE claim selection process is quite different from that of previous probe and educate programs. Whereas earlier, the first rounds of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset. This in turn eliminates burden on providers, who (based on data analysis) are already submitting claims that are compliant with Medicare policy.
Probe Review and Education Process •
•
•
•
•
•
MACs will review 20 to 40 claims from Medicare providers and conduct one-toone, personalized education sessions to address medical billing errors found in the reviewed claims. Each round of 20-40 claim reviews is referred to as a probe. If the MACs review showed overall compliance with Medicare billing regulations or modest billing error rate, the provider will not be subject to audits for at least 12 months. On the other hand, if the review demonstrated a moderate or high error rate in the first audit round, the provider will receive personalized training and face another audit in about 45 days. Similar to the first round, compliant providers in the second round will be exempted from medical reviews for at least 12 months and providers who maintain high or moderate error rates will face a third round of audits. Lastly, if the providers cannot demonstrate Medicare billing compliance even after the completion of three rounds of medical reviews and education, MACs will refer them to CMS for “further action”, which may include total prepay review, extrapolation, and referrals to Unified Program Integrity Contractors (UPICs) or Zone Program Integrity Contractors (ZPICs). Providers/suppliers may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.
The new Targeted Probe and Educate (TPE) program began as a pilot in one MAC jurisdiction in June 2016 and was further expanded to three additional MAC jurisdictions in July 2017. The success of the program during the pilot, including a decrease in appealed claims decisions and increase in the acceptance of provider education, prompted CMS agency leaders to expand the initiative to all MAC jurisdictions later in 2017.
www.outsourcestrategies.com
(800) 670 2809