CMS has directed its contractors to focus on preventing the payment of improper claims.
“Pay and Chase” practices are discouraged.
CMS contractors have been tasked with the responsibility of developing innovative data analysis methodologies for detecting and preventing Medicare fraud and abuse.
Pre Payment & Post Payment Review – Typical Audit issues
Auditors are “missing” vital documentation submitted in response to their request for documents.
In complex medical cases, auditors are citing medical journal findings which are not the current state of the science.
Auditors are using a “cookie cutter” approach when extrapolating damages, failing to take into account the specific characteristics of a given case.
Auditors are readily substituting their medical judgment for that of a treating physician.
Auditors are conducting “interviews” of patients in an effort to determined if the patient was homebound (sometimes as much as a year after the dates of service at issue), and are then denying claims based on these present interviews.
Auditors are applying the wrong LCD when assessing coverage requirements.
Auditors are supposedly comparing a provider’s billing practices to those of his alleged peers despite the fact that the provider’s specialty area was completely different from that of the other providers cited.