Medicare Audit

Have You Received a Notice of Termination of Your Medicare Provider Number?

By Danielle M. Murray, J.D.

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare provider numbers of many different Medicare providers including psychologists and other mental health providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old addresses.

Often the termination is retroactive to a much earlier date the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

1. You are prohibited from reapplying to Medicare for at least two (2) years.

2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).

3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).

4. You may no longer contract with Medicare or anyone who does.

5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.

6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.

7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

1. Don’t bother to write letters.

2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS).

3. Don’t bother to call the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).
4. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).

5. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.

6. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)

What we recommend is:

1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).

2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.

3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.

4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination. Train your management and staff on these.

The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

1. Documents showing how the error occurred or past efforts to comply.

2. Surety bond guarantees and documents (where required).

3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).

4. Current licenses and permits.

5. Certificates of good standing and latest annual reports for any corporation or limited liability company.

6. Print-outs from PECOS/NPPES Registry discussed above.

7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).

8. Certificates of compliance training for you and your staff, if available.

9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.

10. An authorization form for your consultant or attorney to represent you in the matter.

All copies should be clear, legible, complete, straight, no corners cut off an no handwriting on them, to the greatest extent possible.

Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare Issues Now.
The attorneys of The Health Law Firm represent durable medical equipment (DME) suppliers and health care providers in Medicare audits, ZPIC audits, MAC audits and RAC audits throughout Florida and across the U.S. They also represent DME suppliers, physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions, termination from the Medicare or Medicaid Program and administrative hearings.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

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About the Author: Danielle M. Murray is an attorney with 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 Avenue, Altamonte Springs, Florida 32714

“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.

Medicare and Medicaid Audits of Psychologists and Other Mental Health Professionals – Part 2

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Over the past year I have observed an increasing number of Medicare and Medicaid audits being initiated against psychologists and other mental health professionals.

I have recently seen a number of audits initiated against psychologists and mental health professionals who treat assisted living facility (ALF) and skilled nursing facility (SNF) residents. Most often these are audits by the Medicare Administrative Contractor (MAC), because this area of medical practice has been identified as one fraught with fraud and abuse. Sometimes these are only “probe” audits, initial audits requesting one (1) to five (5) medical records. Other times the MAC has been requesting anywhere from 120 to 375 records.

This blog is party two in my series on Medicare and Medicaid audits initiated against psychologist and other mental health professionals. Click here to see part one.

Areas Being Targeted.

In state Medicaid audits, I have recently seen increased scrutiny in the following areas:

1. Pediatric care
2. Therapy (speech therapy, physical therapy, occupational therapy) especially to pediatric patients and developmentally disabled patients.
3. Small assisted living facilities (ALFs), group homes, homes for the developmentally disabled (DD) and other small facilities.
4. Home health agencies.
5. Pediatric dentistry.
6. Optometry care, especially if delivered in a nursing home or assisted living facility (ALF).
7. Ambulance and medical transportation services, especially of nursing homes.
8. Psychiatric psychological and mental health.

Use of Statistical Sampling and Extrapolation Formulas to Multiply Repayment Amounts.

In both state Medicaid audits and in Medicare audits, I have experience increased reliance by the auditing agency on use of mathematical extrapolation formulas to estimate the amount that should be repaid. The formula used usually takes the overpayment that has actually been found and, based on several factors, multiplies it out to many times the actual overpayment amount. Thus, a found overpayment of $2,800 may become a demand for repayment of $280,000, based on the statistical extrapolation.

Things you should know about this are as follows.

1. Neither the Medicare program nor the state Medicaid programs should use an extrapolation formula, unless:

     a. There is a “high” error rate in the claims that have been submitted; or 

b. There have been prior educational efforts or prior audits of the provider, and the      provider has failed to correct the problems in claims submission previously found.

2. The states each have different guidelines, rules or regulations on when they will apply the statistical formula. Some do not use it. Some use a higher percentage error rate to prompt use of the formula and some lower. North Carolina is one of the lowest we have encountered; an error rate of more than five percent (5%) will prompt its Medicaid agency to apply the statistical extrapolation to the recovery amount.

Problems Psychologists and Mental Health Professionals May Encounter Producing Records for Audits.

Many psychologists, therapists and health professionals are being audited because they are treating patients in a nursing facility or assisted living facility.

In most cases, a history, physical, comprehensive assessment, physician orders, diagnosis, medication list, medication administration records, consultations, social service notes and other medial documents being relied upon by the therapist are reviewed and assessed in connection with treatment of the patient. The big problem here is that these usually stay in the facility. When an audit occurs, these may not all be available.

The biggest issue that Medicare and Medicaid seem to be targeting is lack of documented “medical necessity.” The auditors take the position that the audited therapist must produce copies of the documents listed above, in part, to show “medical necessity” for the services provided.

Additionally, most physicians who treat patients in nursing facilities place their own assessments, plans and notes into the facility’s chart and do not retain a copy themselves. When the audit comes, they may not be able to produce copies of their own notes and evaluations.

I recommend that any provider treating residents of nursing homes and assisted living facilties (ALFs):

1. Review the local coverage decision (LCD) applicable to the code(s) you bill so you know what requirements must be met and what documentation is required.
2. Review the Medicaid provider handbook or state regulations for the services you provide if you are a Medicaid provider.
3. Obtain and keep copies of all applicable histories, physicals, care plans, physician orders, physician consults, etc. This is best done by obtaining and using a portable scanner. You can then keep the copies electronically in a properly secured, protected server in your office (backed-up, off site, of course).
4. Sign all of your evaluations, prepare your reports, evaluations progress notes and consultations on your laptop or other computer and sign it electronically before you print it out. Alternatively, if you still use paper, scan the paper copy (after signed) and maintain it electronically.
5. Do not use unusual or non-standard terms and abbreviations. If you do, you must keep an “abbreviations and definitions” list 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 handbook. Also, always include the start time, stop time and total time spent with any resident in your report, evaluation and notes.
7. Be sure the patient, patient’s next of kin/surrogate, patient’s physician or nursing home administrator signs off as having received the services each time. The patient’s signature is preferred.

Contact Health Law Attorneys Experienced in Handling Medicaid Audits.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Healthcare Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (DHHS). Often other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies participate. Don’t wait until it’s too late. If you are concerned of any possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today.  Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

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.