(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 help determine how their coding and billing practices "stack up" when compared to the practices of their peers working in the same specialty area. One question to be addressed is whether your coding and billing practices make you appear as an "outlier." If, in fact, you are an outlier, you should expect to be audited by the Centers for Medicare and Medicaid Services (CMS) or one of its contractors. To be clear, just because you are an outlier does not necessarily mean that you are engaging in improper conduct. Nevertheless, if you are an outlier, we strongly recommend that carefully analyze practices in an effort to identify why your practices differ from those of your peers. Perhaps you are, in fact, improperly coding or billing for services rendered. If so, you will need to determine the scope of any overpayment and work with your legal counsel to promptly reimburse the government. As we have repeatedly advised our clients, "If it isn't your's, give it back." If your practices appear to be correct, what other reasons my explain why your practices differ from those of your peers.
I. Data Mining Tools You Can Use to Assess "Risk":
While you can't completely eliminate the risk of an audit, there are several tools that can help your organization determine how your utilization rates compare to those of your peers. Among these data mining assessment tools is one of our personal favorites - DecisionHealth's "E/M Bell Curve Data Book," which gives a visual overview of the Center for Medicare and Medicaid Services' (CMS') Evaluation and Management (E/M) data rates for 59 different specialties. For instance, a general practitioner can look at his established patient office visits (CPT© codes 99211 - 99215) and compare his utilization rates to the national average for the same CPT© codes. This data can be extremely useful in assessing an office's billing practices and patterns and give confidence to a provider whose rates are similar to the national average.
Another effective data mining assessment tool, especially for non-E/M practices, such as home health agencies and hospices, is the "The Dartmouth Atlas of Health Care," which provides a variety of data tools to evaluate Medicare spending by county. Not only does this interactive website have average-spending-per-Medicare-beneficiary maps, it also has a tool which allows providers to examine national and state benchmarks for a variety of statistics. These include Medicare reimbursements, hospice, skilled nursing facility, and home health agency utilization rates, surgical procedures and more. Applied correctly, this data can be instrumental in a practice's self-evaluation and gives providers significant insight into their own billing patterns.
II. Know Your Appeal Rights:
Unfortunately, staying compliant with Medicare rules and regulations and avoiding audit can be a constant and ever-evolving challenge. Even with the best data mining tools, physicians, group practices, clinics, home health agencies and other providers may still find themselves subject to Medicare post-payment and / or prepayment audit by a Zone Program Integrity Contractor (ZPIC) or by another one of CMS' contractors. ZPICs, Recovery Audit Contractors (RACs) and other Medicare-contractors reviewers are highly knowledgeable and skilled at what they do. They are experienced in handling audits and are quite good at identifying deficiencies in your documentation, regardless of how minor those deficiencies might be. While it is essential to understand your obligations as a Medicare participant, it is equally important to understanding how and why practices get audited. Moreover, it is also necessary to know how to appeal an adverse determination that you sincerely feel is unwarranted.