“Unless you nurture a culture of compliance in your organization, the results of government audits and investigations can be devastating.”
Blazer regarding his appeal 30 days af- ter beginning the process. As of July, he hadn’t heard anything.
Staying off auditors’ radar When he testified to Congress in March 2010, U.S. Department of Health and Human Services (HHS) Inspector Gen- eral Daniel Levinson said the Centers for Medicare & Medicaid Services (CMS) estimated that in fiscal year 2009, $24.1 billion (7.8 percent) of the Medicare fee- for-service claims it paid did not meet program requirements. While not all improper payments involved fraudulent activity, he said CMS shouldn’t have paid the claims.
to phlebology full-time. He performs a large number of varicose vein pro- cedures annually, and Medicare never questioned his coding or billing. All that changed in 2009 when he re- ceived an unpleasant wake-up call from the government’s ZPIC program, part of its effort to eliminate fraud, waste, and abuse in Medicare. TrailBlazer Health Enterprises, the Medicare administra- tive contractor (MAC) for Texas, asked Dr. Clark to submit 46 random patient charts for review. All of the charts Trail- Blazer obtained were for 2007–08. “By 2009 I had done several thousand
procedures without a word from Medi- care,” he said. “In December 2010, Trail- Blazer informed me I owed $800,000 because none of the 46 patient charts complied with Medicare local coverage determination (LCD) criteria.” An LCD is a decision on whether a particular medi- cal service is reasonable and necessary. By now, many physicians are famil- iar with the Recovery Audit Contractor (RAC) program, which recently began focusing audits on practitioners in Tex- as. (See “RACs Target Texas Physicians,” pages 26–28.) But Dr. Clark’s Austin at- torney, Mark Chouteau, JD, says many doctors may not be aware of ZPICs. At
22 TEXAS MEDICINE September 2011
press time, Mr. Chouteau represented 10 physicians targeted by ZPICs. ZPICs perform a range of medical re-
view, data analysis, and Medicare audits. While the audits share many similarities with other Medicare audits, they do dif- fer in one key aspect: potential Medicare fraud implications.
In general, government regulators have the power to assess administrative penalties, impose sanctions, and obtain an injunction to prevent disposition of the wrongdoer’s assets, plus they can coordinate with other civil and criminal investigative agencies. The Department of Justice and state prosecutors can seek criminal sanctions, as well. Dr. Clark explains that TrailBlazer arrived at the $800,000 payment by extrapolating 1,800 patient encounters from the 46 charts covering 2007–08. “They denied every one of those pro-
cedures to the tune of $800,000. They didn’t find any evidence of fraud and didn’t levy any fines, but they wanted close to $1 million from me in two weeks. My other option was to appeal the decision,” he said. With Mr. Chouteau’s help, he began the appeal process on Dec. 31, 2010. Dr. Clark expected to hear back from Trail-
The federal government has made a concerted effort to augment its fraud and abuse efforts in the health care industry. According to Mr. Chouteau, physi- cians must learn to work under in- creased federal scrutiny and understand the government’s fraud and abuse inves- tigation initiatives. He says physicians and their staff members should monitor and improve business and clinical sys- tems, routinely audit claims submissions, and track and evaluate claim denials as part of a working compliance program. “Unless you nurture a culture of com- pliance in your organization, the results of government audits and investigations can be devastating,” he said.
Physicians and their billing staff should monitor online reports by HHS Office of Inspector General (OIG),
http://oig.hhs.gov/reports-and-publica tions/oas/
cms.asp, and the CMS Com- prehensive Error Rate Testing (CERT) program,
http://www.cms.gov/CERT/ CR/
list.asp, to determine improper pay- ments the federal government has iden- tified nationwide. CERT measures the accuracy of Medi-
care fee-for-service payments. CMS cal- culates a compliance error rate (which measures how well they prepared claims for submission) and a paid claims error rate (which measures how accurate- ly carriers, fiscal intermediaries, and MACs made coverage, coding, and other claims-payment decisions) for specific contractors, service types, and health professionals.
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