Strategic Health Solutions is Merely the Latest CMS Contractor to Flex its Audit Muscles

Checklist - Liles Parker

(May 9, 2013): Strategic Health Solutions is an Omaha, Nebraska-based company that provides professional health care education and audit services for both federal and state government agencies. In recent months, a wide range of physicians (working in specialty areas ranging from endocrinology to pain management) have received audit letters asking for supporting documentation associated with the Evaluation and Management (E/M) code billed in connection with a specific patient and date of service. In most instances, the post-payment audits conducted have focused on CPT Codes 99214 and 99215. Accompanying letters sent with the contractor's request have typically noted that the physician's billing practices were higher than those of his / her peers. The purpose of this article is to discuss the various audits now being handled by Strategic Health Solutions and to discuss ways that a physician can reduce his / her level of risk and the avoid being subjected to a post-payment audit.

I. Overview of Work Performed by Strategic Health Solutions:

Strategic Health Solutions has been awarded multiple prime contracts by the Centers for Medicare and Medicaid Services (CMS). Areas worked by Strategic Health Solutions include:

  • Supplemental Medical review Contractor.
  • Medicare Outreach and Quality Assurance.
  • Part D Formulary and Benefits Review Contractor.
  • Medicare Secondary Payor Integration Contractor.
  • Risk Adjustment Data Validation / Intake Medical Review Contractor.
  • Medicare Part C and Part D Program Integrity Technical Assistance.
  • Education Medicaid Integrity Contract (Education MIC) Task Order 1.
  • Education Medicaid Integrity Contract (Education MIC) Task Order 2.
  • Quality of Care Monitor.
  • Specialty Medical Review of Medicare Part A and B Claims.
  • Medicare Prescription Drug Benefit Part D Payment Process Support Services.

As a review of the company’s activities will show, Strategic Health Solutions has been very active working with both the Medicare and Medicaid programs around the country. In recent years, the organization has performed educational, quality assurance, specialty audit and general post-payment review services for federal and state government agencies.

II. Strategic Health Solutions Will Work as a “Supplemental Medical Review Contractor”

In 2012, Strategic Health Solutions was awarded a five-year contract by CMS to serve as a “Supplemental Medical Review Contractor." In this capacity, the organization has been tasked with performing post-payment audits of Medicare Part A, Medicare Part B, and Durable Medical Equipment claims submitted by health care providers and suppliers around the country. Importantly, the contractor has been employing statistical sampling and extrapolation practices, thereby significantly magnifying any projected overpayments identified through the contractor’s efforts. Supplemental audits recently conducted have included the examination of Evaluation and Management (E/M) claims while specialty audits have focused on pain management services and procedures.

III. Steps You Can Take to Prepare for an Audit by Strategic Health Services

At the outset, it is important to keep in mind that the steps you need to take to reduce the likelihood of claims deficiencies are essentially the same as those you would employ to prepare for a post-payment audit of Medicare claims by a Zone Program Integrity Contractor (ZPIC) or a Recovery Audit Contractor (RAC). As we have previously discussed, after analyzing the various medical necessity, coverage, coding and billing requirements required for a claim to qualify for payment, we have identified "Seven Elements of a Payable Claim". Medicare Part A, Medicare Part B and Durable Medical Equipment claims can be comprehensively assessed using this tool. Health care providers and suppliers should carefully analyze their practices to better ensure that all regulatory and statutory requirements which cover a particular claim have been met prior to billing Medicare for the services or supplies at issue. An abbreviated overview of these seven elements includes:

Element #1: Medical Necessity of Services / Supplies Provided.

Element #2: Were these Services / Supplies Actually Provided?

Element #3: Were these Services / Supplies “Tainted” Due to a Violation of Law?

Element #4: Do the Services / Supplies Qualify for Coverage?

Element #5: Is Your Documentation of these Services / Supplies Complete?

Element #6: Are your Services / Supplies Properly Coded?

Element #7: Did You Properly Bill for the Services / Supplies Rendered Correctly?

V. Conclusion

Each year, the level of scrutiny currently being levied on health care providers and suppliers has continued to increase. The current post-payment audits being conducted by Strategic Health Solutions are merely the latest iteration of this trend. As a participating provider or supplier in the Medicare program, you and your practice are obligated to comply with each and every regulatory / statutory requirement which applies to the specific services / supplies you are billing to the Medicare program. If your practice is audited by Strategic Health Solutions, we recommend that you consult with a health lawyer experienced in responding to this and other post-payment reviews by a contractor (such as Strategic Health Solutions) working for CMS.

Robert Liles represents health care providers in audits by Strategic Health Solutions.

Robert W. Liles, J.D., M.B.A., M.S., represents physicians and other health care providers in Medicare post-payment audits, prepayment reviews, and in similar assessments conducted by program integrity contractors hired to support the Medicaid program. In addition, Robert counsels clients on regulatory compliance issues, performs gap analyses, conducts internal reviews, and trains healthcare professionals on various legal and compliance issues. For a free consultation, call Robert today at 1-800-475-1906.