By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
Numerous health care professionals (including physicians, therapists, counselors, DME providers, ALFs, group homes, and psychologists) have been placed on prepayment review after not challenging Medicare or Medicaid audit results. This prepayment review often delays payments for months, potentially forcing providers out of business, which may be the intended outcome of the auditing contractor or agency.
What Happens on a Prepayment Review?
A Real-Life Example of the Trouble Caused by a Medicare Audit.
However, since the amount demanded back by the MAC was only a few thousand dollars, the therapist never hired an attorney and never challenged the results. Instead of retaining legal counsel and appealing the results, the therapist paid the entire amount, thinking that was the easy way out.
Sadly, because the error rate was so high, the company handling Medicare put the therapist’s claims under review right away, thinking the earlier check had found cheating or purposely wrong codes. From then on, every bill the therapist sent had to be on paper, with the patient’s medical records mailed in. The company would not decide on any claims; instead, they held them, asking for more papers and details now and then. Right now, most of the therapists’ bills are stuck in this review, some for up to five months without a decision. Because there’s no decision, he can’t get a review or appeal.
The therapist conveyed to me that he recently contacted the auditor to attempt to obtain decisions on some of his claims so that he could at least begin the appeal process if the claims are denied. He advised me that the auditor at the MAC expressed surprise that he was still in business.
Challenge Improperly Denied or Reduced Claims.
These situations are very unfair and unjust, especially to smaller health care providers. The reduced cash flow even for a month or two may be enough to drive some small providers out of business. Larger health care providers have vast resources sufficient to handle such audit situations on a routine basis. They may have similar problems but are better equipped and have more resources to promptly handle it. Rather than immediately pay whatever amount is demanded on an audit and waive any appeal/review rights, the provider should review each claim denied or reduced and challenge the ones that have been improperly denied or reduced. Otherwise you may wind up with a high error rate which will cause you to be placed into prepayment review. Once placed in prepayment review, it is difficult to get out of it. Often it takes six months or longer.
Don’t Get Caught Up in the Audit Cycle.
Another reason to challenge overpayment demands as a result of an audit is because the audit contractors will keep you on an audit cycle for a number of future audits if they are successful in obtaining any sort of significant recovery from you on the initial audit. This is similar to what happens if your tax return is audited by the Internal Revenue Service (IRS) recovers a significant payment from you because you did not have the documentation to support your deductions, you can expect to be audited for at least the next two years.
The value of competent legal representation at the beginning of an audit cannot be overestimated. It is usually long after the audit is over, and the time to appeal the audit agency’s findings has passed, that the health care provider realizes he should have retained an audit consultation.
Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.
The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.
Comments?
Have you ever been audited? What was the process like? Did you retain legal counsel to help with the process? Was having legal assistance worth it? Please leave any thoughtful comments below.
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.
