Search
  • Michael Breslin

Types of Medicare Audits

Targeted Probe and Educate (TPE) Audits

· CMS authorizes its MAC’s to conduct Medicare audits of providers and suppliers whose errors rates are higher than their peers related to:

o Billing practices

o Utilization rates (allowables)

· MACs also target providers and suppliers that bill for HCPCS or services with high national errors rates or are focused items/HCPCS

· Includes up to three rounds of reviews and includes 20-40 claims reviewed per round

· If you pass the first round, you will not be reviewed again for that HCPCS, by that contractor, for a year. All other reviews by that MAC and other MACs remain in play

· If provider/supplier does not pass the first round, the MAC will conduct an education session with the provider/supplier and then wait at least 45 days to begin the 2nd round of review.

· If provider/supplier does not successfully pass the review within the three rounds, then the MAC will refer the provider/supplier to CMS for further disciplinary actions that may include:

o 100% pre-pay audits for all claim

o 6-month suspension of billing privileges

o Revocation of Medicare license

o Referral to OIG for criminal investigation

Recovery Audit Contractors (RACs)

· These are companies who are contracted by CMS to identify overpayments and underpayments

o Overpayments are returned to the Medicare Trust Fund

o Underpayments are paid to the provider/supplier

· RACs are HIGHLY motivated and COMPENSATED to focus and find overpayments

o RACs generally receive 9%-12.5% of the overpayments that are returned to the Medicare Trust fund.

o RAC’s found over $900,000,000 in improper payments between 2015 and 2016 alone

§ Approximately, only 18% were underpayments.

Zone Program Integrity Contractors (ZPICs)

· Charged with implementing and enforcing the Medicare Benefit Integrity program

· Involves identifying cases of Fraud: the most serious of audits as these are fraud-based investigations, whereas, RACs, MACs, and TPEs typically are error based.

· ZPICs utilize a variety of proactive and reactive techniques to identify and address any potential fraudulent billing practices.

o This can be via ADRs which could cause great financial damage to the provider/supplier, due to the fact, that all documentation must be submitted, and the appeals process must be completed before the provider/supplier can get paid on the claim

· ZPICs receive referrals from RACs and MACs in additional to their own data analysis to identify potential fraud

· ZPICs utilize date mining from other audits, processed claims, data sharing amongst the various Medicare contractors, etc.

5 views

ADDRESS

900 SE Federal Highway

Suite 321, Stuart, FL 34994

CONTACT

Tel: 888-304-2480

Email: info@boost-llc.com

SERVICES

WHAT WE DO...

Boost Advisory Group are experts in DME consulting, DME revenue optimization, Brightree consulting and optimization, DME business process outsourcing, Medicare TPE, RAC, and UPIC audit response services, executive coaching, operational development, Analytics and reporting optimization to improve topline and bottom line. We are experts in helping our clients grow their business by reaching operational and financial excellence.

Boost Advisory Group is an independent company that is not associated, or affiliated, with Brightree ® or any software provider and therefore our clients can leverage our deep industry knowledge without bias, so they can receive a fair and objective advantage.

© 2020 by Boost Advisory Group LLC. 

  • LinkedIn
  • YouTube
  • Twitter