How should a provider respond if their practice is placed on prepayment review?
Perhaps most importantly, DON’T IGNORE THE PROBLEM.
Hoping that the review will just “go away” is wishful thinking.
Providers should also keep in mind that a poor showing in connection with a prepayment audit, can lead to:
- Postpayment audit.
- Referral to CMS for possible suspension action.
- Referral to CMS for possible removal from the Medicare program.
- Referral to HHS-OIG for possible CMP, False Claims Act and / or criminal enforcement.
- Referral to DOJ for possible.
Are you reviewing your claims and associated documentation before sending it in for review?
Was the care medically necessary?
Is there evidence that the services were actually provided?
Are there any statutory violations?
Have all coverage requirements been met?
Was the claim properly coded?
Was the claim properly billed?
The bottom line is simple — in order to have a prepayment review terminated, you have to be able to show the reviewing ZPIC that you fully understand and are complying with statutory and regulatory requirements.
What you are finding when you review your claims?
When faced with the realization that your practice or clinic has been submitting improper billings to one or more government health care programs, it is important to remember one of life’s first lessons —
“If it doesn’t belong to you, give it back.”
In the case of a prepayment review, you won’t have an overpayment with respect to the specific claim at issue. Nevertheless, you need to ask yourself, is the mistake identified indicative of a broader problem? If so, you will need to conduct an internal review of other problematic claims to ensure that no improper claims have been submitted to Medicare and paid by the government.
Keep in mind that unlike a postpayment audit, there is no administrative appeals remedy if a provider is placed on prepayment review. In light of the average length of time we have seen, being placed on prepayment review can be devastating for a provider with a high Medicare patient workload.
Seeking judicial relief in a prepayment review is expensive and likely to fail. Unfortunately, most attempts we are aware of to get a Federal Judge to intervene have not succeeded. Moreover, it has the added headache of putting your practice’s problems in front of a Federal Asst. U.S. Attorney (only DOJ has independent litigation authority). Do you really want to have your problems reviewed at this level?
While there is no “quick” answer, through hard work you can get off of prepayment review. Working with your attorney and outside experts, you can systematically address the problems raised.