Over the past year, I have seen an increasing number of Medicare and Medicaid audits launched against psychologists and other mental health professionals.
I have recently seen a number of audits initiated against psychologists and mental health professionals who treat residents of assisted living facilities (ALFs) and skilled nursing facilities (SNFs). In most cases, these are audits conducted by the Medicare Administrative Contractor (MAC), because this area of medical practice has been identified as riddled with fraud and abuse. Sometimes these are just “probe” audits, initial audits that ask for one (1) to five (5) medical records. Other times, the MAC has been requesting between 120 and 375 records.
Area Program Integrity Contractors (ZPIC).
Area Program Integrity Contracts (ZPIC) are Medicare’s premier fraud detection contractors. If a poll audit, MAC audit, or other audit investigation suspects fraudulent billing, the ZPIC can enter. The ZPIC also identifies and targets various CPT codes, medical practice areas, services and equipment that are highly susceptible to fraud. You will then initiate a ZPIC audit on your own. ZPICs receive bonuses based on the amounts they recover for the Medicare program.
OIG Annual Work Plan.
The Office of the Inspector General (OIG) publishes a work plan each year that analyzes the areas, types of medical services, CPT codes, equipment and tests that it considers most susceptible to fraud and abuse. The new plan is usually published in the fall for the business year. It is available online.
Psychiatrists, psychologists, and mental health counselors, as well as facility managers, compliance officers, attorneys, and billing and coding experts should review this work plan each year to learn what the OIG considers to be fraud and abuse. and because. Measures must be implemented immediately to remedy any problems that are identified in your practice or facility.
Qui Tam or Whistle Blower cases.
In many cases, an audit or investigation may be called against a facility, individual, or group, based on the filing of a qui tam or whistleblower case. However, you will not know this because these cases are filed under seal and remain sealed, often for years. These lawsuits are based on false claims that have been submitted for Medicare, Medicaid, Tricare, the Veterans Administration (VA), or any other federal or state program. They are usually introduced by disgruntled former employees. These can cause any of the types of audits discussed above to be initiated.
If you suspect this has happened, you should immediately retain legal counsel to represent you or your organization. If OIG Special Agents (S/A) or Federal Bureau of Investigation (FBI) agents are involved, you would be foolish not to retain an experienced health law attorney before speaking with someone.
Medicaid audits.
I have also seen an increase in Medicaid audits by state agencies.
Medicaid audits are generally initiated by the program integrity section or division of the state agency that administers the Medicaid program, or one of the agency’s contractors. States are under increasing pressure from the federal government to be much more aggressive in identifying Medicaid fraud and recovering overpayments.
If Medicare or any of its contractors recover an overpayment from a provider, they will also notify the state Medicaid program and the Tricare program. These will initiate audits and collection actions.
State ZPICs.
States are now hiring ZPIC to help detect fraud and recover large overpayments from Medicaid providers. Additionally, Medicare ZPICs can also detect and recover Medicaid overpayments.
Targeted areas.
In state Medicaid audits, I have recently seen increased scrutiny in the following areas:
1. Pediatric care2. Therapy (speech therapy, physical therapy, occupational therapy) especially for pediatric patients and patients with developmental disabilities.
3. Small assisted living facilities (ALF), group homes, homes for people with developmental disabilities (DD), and other small facilities.
4. Home health agencies.
5. Pediatric dentistry.
6. Optometric care, especially if provided in a nursing home or assisted living facility (ALF).
7. Ambulance services and medical transport, especially nursing homes.
8. Psychiatric psychological and mental health.
Use of extrapolation formulas and statistical sampling to multiply reimbursement amounts.
In both state Medicaid audits and Medicare audits, I have experienced increased reliance by the auditing agency on the use of mathematical extrapolation formulas to estimate the amount to be reimbursed. The formula used generally takes the overpayment that has actually been found and, based on various factors, multiplies it by several times the actual amount of the overpayment. Therefore, a found overpayment of $2,800 can be converted into a claim for refund of $280,000, based on statistical extrapolation.
The things you should know about this are as follows.
1. Neither the Medicare program nor the state Medicaid programs must use an extrapolation formula, unless:
has. There is a “high” error rate in the claims that have been filed; Prayed
b. There have been prior educational efforts or prior audits of the provider, and the provider
has not been able to correct the problems previously found in the claims submission.
2. Each state has different guidelines, rules, or regulations on when they will apply the statistical formula. Some don’t use it. Some use a higher percent error rate to drive formula usage, and others use a lower one. North Carolina is one of the lowest we have found; an error rate of more than five percent (5%) will cause your Medicaid agency to apply the statistical extrapolation to the recovery amount.
Problems psychologists and mental health professionals may encounter when producing audit records.
Many psychologists, therapists, and health professionals are being audited because they treat patients in a nursing facility or assisted living facility.
In most cases, a history, physical exam, comprehensive evaluation, physician orders, diagnosis, medication list, medication administration records, consultations, social service notes, and other medical documents related to the patient are reviewed and evaluated. therapist in relation to the treatment of the patient. . The big problem here is that these usually stay in the installation. When an audit occurs, not everyone may be available.
The biggest problem Medicare and Medicaid seem to be targeting is the lack of documented “medical necessity.” The auditors take the position that the audited therapist must submit copies of the documents listed above, in part, to demonstrate the “medical necessity” of the services provided.
Also, most physicians who treat patients in nursing facilities place their own assessments, plans, and notes in the facility’s file and do not keep a copy. When the audit comes, they may not be able to produce copies of their own notes and assessments.
I recommend that any provider who treats nursing home and assisted living facility (ALF) residents:
1. Review the Local Coverage Decision (LCD) applicable to the codes you bill to see what requirements must be met and what documentation is required.2. Check your Medicaid provider manual or state regulations for the services you provide if you are a Medicaid provider.
3. Obtain and keep copies of all history, physical exams, plans of care, medical orders, doctor visits, etc. applicable. This is best done by obtaining and using a portable scanner. You can then store the copies electronically on a properly secured and protected server at your office (backed up, off-site, of course).
4. Sign all of your assessments, prepare your reports, assessment progress notes, and consultations on your laptop or other computer and sign them electronically before printing. Alternatively, if you’re still using paper, scan the paper copy (after signing) and store it electronically.
5. Do not use unusual or non-standard terms and abbreviations. If you do, you must maintain a list of “abbreviations and definitions” and produce it with your records in any audit response.
6. In your reports, evaluations, and notes, use the terminology from the LCD and Medicaid Provider Manual. Also, always include the start time, end time, and total time spent with any resident in your report, evaluation, and notes.
7. Have the patient, the patient’s next of kin/surrogate, the patient’s physician, or nursing home administrator sign each time services are received. Patient signature is preferred.
Contact health law attorneys experienced in handling Medicaid or Medicare audits.
Medicaid and Medicare fraud is a serious crime and is vigorously investigated by the state MFCU, Agency for Health Care Administration (AHCA), Area Program Integrity Contractors (ZPIC), FBI, Office of the Inspector General (OIG) of the Department of Health and Human Services (DHHS). Other state and federal agencies are often involved, including the US Postal Service (USPS) and other law enforcement agencies. Don’t wait until it’s too late. If you are concerned about potential violations and would like a confidential consultation, contact a qualified health attorney who is familiar with medical billing and auditing today. Criminal charges for Medicaid and Medicare fraud often arise from routine Medicaid and Medicare audits, investigative audits, or patient complaints.
Health Law Firm attorneys routinely represent physicians, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health agencies, nursing homes, group homes, and other health care providers in investigations, audits, and actions. recovery from Medicaid and Medicare.
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