Medicare and Medicaid Audits

MEDICARE AND MEDICAID AUDITS

Experience, confidentiality, the right team plus proven software.

The HPP Management Group has represented physicians in over 500 Medicare and Medicaid audits of overpayment assessments, has participated in more than 50 A L J hearings and has recovered millions of dollars for our clients.  

The knowledge acquired in the audits served as the basis to develop the AccuChecker Product Line, so we developed proven software that enables us to maximize recovery amounts from Audits.  

Our success is measured on key factors we treat each AUDIT with a unique approach:  

Working directly with the audited physician and the key staff.

Our forensic analysis experience permits us to view and closely analyze each transaction denied or reduced in reimbursement by the carrier. 

The forensic analysis includes implementing software scrubbing claims techniques that allow us to follow Medicare and Medicaid reimbursement guidelines and to prepare undisputable rebuttals to the Carriers’ decisions:

·         Preparing a detailed rebuttal to each denial or reduction in reimbursement

·         Compiling a summary rebuttal report that includes all transactions affected 

We have assisted many physicians affected with Prepayment Review situations with Medicare and Medicaid. The Prepayment Review - a lengthy and painful process, that requires continuous scrutiny and follow up. We have been able to successfully correct every Prepayment Review with patience and creating a team effort with the medical practice.

We limit our practice handling Medicare and Medicaid AUDITS as well as Prepayment Review Cycles to overpayment assessments from Medicare, Medicaid and other insurance carriers. We have represented cases with overpayments assessment from small amounts to over one (1) million dollars.

We recognize that there are cases that present legal issues that transcend the normal overpayment assessment or prepayment review cycle, in cases of that nature we refer the case to a healthcare care law firm that have the experience needed to assist our clients, limiting our services to what we do well – AUDITS of Overpayment Assessments.

 

FOR MORE INFORMATION PLEASE CONTACT:

HPP Management Group, Corp.

Developers of the AccuChecker Product Line

Phone: (305) 227-2383

Email: support@accuchecker.com

 

Join Us:

Like Us on Facebook:           https://www.facebook.com/Accuchecker

Follow US on Twitter:          https://twitter.com/HPPAccuchecker

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Scope of Various Audits

Scope of Various Audits

What is the scope of the various types of audits? Who will be conducting the audits, and what are the look-back periods (the period of time in which an auditor can review claims that have been submitted for payment) for each audit?

 

SCOPE, AUDITOR, AND LOOK-BACK PERIOD
Name	Scope	Auditor	Look-back period
Medicare RACs Focus: Medicare overpayments and underpayments	Medicare RACs identify Medicare fee-for-service overpayments and underpayments and collect overpayments as well as return underpayments. Medicare RACs operate nationwide and only review issues approved for review by CMS.	The four Medicare RACs, each responsible for a U.S. region, are private companies that have contracted with CMS. Medicare RACs are paid on a contingency fee basis, receiving a percentage of both the overpayment and underpayments they correct.	Medicare RACs perform audit and recovery activities on a postpayment basis and may review a claim up to three years after the date the claim was filed.
Medicaid RACs Focus: Medicaid overpayments and underpayments	Medicaid RACs identify all providers’ underpayments and overpayments of Medicaid claims and recoup the overpayments. Medicaid RACs operate nationwide on a state-by-state basis. States have discretion to determine what areas of their Medicaid programs to target and are not required to publicly announce audit target areas.	Each state contracts with a private company that operates as a Medicaid RAC to perform audits of Medicaid claims. Individual states determine how each Medicaid RAC will be paid, usually on a contingency fee basis.	Medicaid RACs perform audit and recovery activities on a postpayment basis and may not review a claim more than three years after the date the claim was filed, unless the Medicaid RAC has approval from the state.
MICs Focus: Medicaid overpayments and education	MICs review all Medicaid providers to identify high-risk areas, overpayments, and areas for provider education to reduce Medicaid fraud and abuse.	MICs are companies contracted by CMS, which has divided the U.S. into five MIC jurisdictions, each encompassing two CMS regions. MICs are not paid on a contingency fee basis, but are eligible for financial incentives based on the effectiveness of their audits.	MICs perform audit and recovery activities on a postpayment basis and may review a claim as far back as permitted under the laws of the states that have paid the claims (generally a five-year look-back period).
ZPICs Focus: Medicare fraud, waste, and abuse	ZPICs investigate potential Medicare fraud, waste, and abuse and refer these cases to their associated MAC for recoupment or to other federal and state agencies for other penalties. The goal of ZPICs is to identify fraud, not to conduct random audits.	ZPICs are companies contracted by CMS, which has divided the U.S. into seven ZPICs jurisdictions, each aligned with one to two MACs. ZPICs are not paid on a contingency fee basis.	ZPICs have no specified look-back period.
MFCUs Focus: Medicaid fraud, waste, and abuse	MFCUs, which are annually certified by the OIG, investigate and prosecute (or refer for prosecution) criminal and civil Medicaid fraud cases.	Each state, except North Dakota, has an MFCU, which is jointly funded on a matching basis with the federal government.	MFCUs have no stated look-back period.
CERT Focus: Medicare improper payment rate	The CERT program identifies and estimates the rate of improper payments in the Medicare program and publishes an annual report describing national paid claims and provider compliance error rates. CERT program findings are not considered a measure of fraud because CERT randomly samples claims, rather than examining billing patterns that indicate potential fraud.	CMS runs the CERT program using two private contractors.	The CERT program reviews Medicare claims on a postpayment basis. The reviewed claims are limited to the current fiscal year (October 1 to September 30).
PERM Focus: Medicaid improper payment rate	The PERM program identifies and estimates the rate of improper payments in Medicaid and the Children’s Health Insurance Program. Individual state error rates are measured and are then combined to extrapolate a national error rate. The PERM program findings are not considered a measure of fraud because PERM randomly samples claims, rather than examining billing patterns that indicate potential fraud.	CMS runs the PERM program using two private contractors.	The PERM program reviews Medicaid claims on a postpayment basis limited to the current fiscal year (the complete measurement cycle is 22 to 28 months).

For more details:

Join AccuChecker at YahooGroups for OnLine chat or one of our many Webinar…

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HPP Management Group

5201 Blue Lagoon Drive

Suite 800

Miami, Florida 33126

Phone:  305-227-2383 or 1-877-938-9311

 

Email : support@accuchecker.com

 

 

Medicare and Medicaid Audits

Medicare and Medicaid Audits

Health care fraud is a persistent and costly problem both for commercial and government payors. The Centers for Medicare & Medicaid Services (CMS) estimates that a significant amount of fee-for-service payments are misspent on improper payments every year. To address health care fraud, Congress and CMS have developed a variety of approaches over the past several years to audit Medicare and Medicaid claims. The tables in this article summarize the major types of Medicare and Medicaid audits that could affect physicians. Entities responsible for these audits include:

 

Ø  Medicare Recovery Audit Contractors (RACs)

Ø  Medicaid RACs

Ø  Medicaid Integrity Contractors (MICs)

Ø  Zone Program Integrity Contractors (ZPICs)

Ø  State Medicaid Fraud Control Units (MFCUs)

Ø  Comprehensive Error Rate Testing (CERT)

Ø  Payment Error Rate Measurement (PERM)

 

 

Have you been contacted regarding a potential audit?

Do you have concerns of an Audit ? 

Join AccuChecker at YahooGroups for OnLine chat or one of our many Webinar…

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HPP Management Group

5201 Blue Lagoon Drive

Suite 800

Miami, Florida 33126

Phones: 305-227-2383 or 1-877-938-9311

support@accuchecker.com

 

HPP - Medicare and Medicaid Audits

MEDICARE AND MEDICAID AUDITS

Experience, confidentiality, the right team plus proven software

 

The HPP Management Group has represented physicians in over 500 Medicare and Medicaid audits of overpayment assessments, has participated in more than 50 A L J hearings and has recovered millions of dollars for our clients.

The knowledge acquired in the audits served as the basis to develop the AccuChecker Product Line, so we developed proven software that enables us to maximize recovery amounts from Audits.

Our success is measured on key factors we treat each AUDIT with a unique approach:

·         Working directly with the audited physician and the key staff 

·         Our forensic analysis experience permits us to view and closely analyze each transaction denied or reduced in reimbursement by the carrier 

The forensic analysis includes implementing software scrubbing claims techniques that allow us  to follow Medicare and Medicaid reimbursement guidelines and to prepare undisputable

            rebuttals to the Carriers’ decisions

       ·         Preparing a detailed rebuttal to each denial or reduction in reimbursement

 

·         Compiling a summary rebuttal report that includes all transactions affected

 

We have assisted many physicians affected with Prepayment Review situations with Medicare and Medicaid. The Prepayment Review - a lengthy and painful process, that requires continuous scrutiny and follow up. We have been able to successfully correct every Prepayment Review with patience and creating a team effort with the medical practice. 

We limit our practice handling Medicare and Medicaid AUDITS as well as Prepayment Review Cycles to overpayment assessments from Medicare, Medicaid and other insurance carriers. We have represented cases with overpayments assessment from small amounts to over one (1) million dollars. 

We recognize that there are cases that present legal issues that transcend the normal overpayment assessment or prepayment review cycle, in cases of that nature we refer the case to a healthcare care law firm that have the experience needed to assist our clients, limiting our services to what we do well – AUDITS of Overpayment Assessments

 

FOR MORE INFORMATION PLEASE CONTACT:

HPP Management Group, Corp.

Developers of the AccuChecker Product Line

Phone: (305) 227-2383 Email: sales@accuchecker.com

  

 

Our Social Sites

 

 

 

• Like Us on Facebook:           https://www.facebook.com/Accuchecker
• Follow US on Twitter:          https://twitter.com/HPPAccuchecker
• Join our Group:                    https://www.facebook.com/groups/1467439953488495/

 

Yahoo Group:                       https://groups.yahoo.com/neo/groups/accuchecker/info

The Medicare Audit Process

The Medicare Audit Process

Medicare providers and supplies should expect audit contractors to attempt to identify improper payments resulting from:

·   Incorrect payment amounts;

·   Non-covered services (including services deemed medically unnecessary);

·   Incorrectly coded claims; and

·   Duplicate claims

The Medicare claims appeal process has several levels of appeal: redetermination, reconsideration, Administrative Law Judge, Medicare Appeals Council, and finally, judicial review.  There are different time periods and claims amount requirements for each of these levels, and adherence to these requirements is necessary.

Since 1983 we have been helping physicians to operate practices as a business, over 500 Medicare and Medicaid audits have given us the knowledge to develop the AccuChecker Product Line including Claims Scrubbers and for the 10 years we have been involved in HMOs Risk Management and have developed the MCAR Reports – Managed Care Reports.

For more details:

HPP Management Group, Corp.

Developers of the AccuChecker Product Line

Phone: (305) 227-2383

Email: support@accuchecker.com

Website: http://www.accuchecker.com

 

Our Social Sites:

·         Like Us on Facebook:           https://www.facebook.com/Accuchecker

·         Follow US on Twitter:          https://twitter.com/HPPAccuchecker

·         Join our Group:                    https://www.facebook.com/groups/1467439953488495/

 

Yahoo Group:                       https://groups.yahoo.com/neo/groups/accuchecker/info