Physicians and Physician Groups Subject to RAC and Medicare Audits
It is important for all Medicare providers and suppliers, including physicians and physician groups, to prepare for RAC audits. One important step to prepare for RAC audits is for Medicare providers and suppliers to identify potential areas of focus for the RAC auditors, in order to ensure that the providers and suppliers have adopted and implemented appropriate compliance plans.
Reviewing the categories of claims denied during the RAC demonstration program (which are published as part of the RAC Demonstration Evaluation Report), and reviewing other CMS guidance (e.g., the annual OIG Work Plan document) can assist providers to determine potential areas of RAC scrutiny. CMS has identified the following areas as areas for targeted review, among others:
- Place of service errors;
- Evaluation and Management ("E/M") services; and
- "Incident to" billings.
Physicians and physician groups must prepare now for increased Medicare scrutiny of these types of claims, among others.
Wachler & Associates, P.C., has represented providers, suppliers and other healthcare entities subject to Medicare audits and claim denials for over 20 years. Some of our firm's more recent Medicare appeals experience includes the following:
- Our firm defended a Medicare audit of a physician requesting that the provider repay over $2.3 million. As a result of the hearing, the overpayment demand was reduced to $89,000, or just 3.5 percent of the original request.
- Our firm defended a Medicare audit of a physician requesting that the provider repay the Medicare program over $200,000. As a result of the Administrative Law Judge hearing, the overpayment demand was reduced to $0.
- Our firm defended a Medicare audit of a physician requesting that the provider repay the Medicare program over $2.5 million. As a result of the Administrative Law Judge hearing, the overpayment demand was reduced to $0.
- Our firm represented a provider group faced with a Medicare audit requesting that the group repay the Medicare program over $850,000. Following the Administrative Law Judge hearing, the overpayment demand was reduced to only $68.
- Our firm represented a hospice entity, which had been subject to an audit of its services provided to 17 beneficiaries. In that case, we received 14 favorable decisions on the record, without even the need for a hearing.
- Our firm currently represents a large health system that was subject to RAC auditing during the RAC demonstration program. Of the appeals we have filed to date on behalf of this organization, our success rate approximates 90 percent.
- Our firm currently represents a hospice entity that was subject to pre-payment review. To date, our law firm has been successful to return over $4 million to the entity, with a high success rate. As a result of these successes, the hospice was removed from pre-payment review.
Attorneys at our firm are frequently asked to write and speak to physician organizations regarding RAC audits and Medicare appeals. For example, our attorneys have been asked to write and speak to the organizations listed below, among others:
"Audit Impact: Expanded Liability for Overpayments," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq.,The RAC Monitor, July 2011.
"Weathering a Medicare Audit: Overview of the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., MGIS Talking Points Newsletter, Vol.2 No. 3, June 23, 2011.
"Contractor Involvement in the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, June 13, 2011.
"One Year Later The Impact of Health Care Reform on Health Care Provider Audits and Compliance Programs," Andrew B. Wachler, Esq., Jennifer Colagiovanni, Esq., and Christopher J. Laney, Esq., Michigan Bar Journal, June 2011.
"The Use of Payment Suspensions in the Audit Landscape," Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, March 24, 2011.
"Prepare for Increased RAC Activity in 2011," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., Wachler & Associates, The RAC Monitor, December 7, 2010.
Speaking Engagements
"RACs, ZPICs, and More - The Latest Improper Payment Initiatives for Governing Audits," MGMA Webinar regarding Recent Proper Payment Initiatives, May 12, 2011.
"Preparing for and Surviving a Third Party Payor Audit," Indiana Medical Society in Merrillville, IN, April 27, 2011.
"The New Landscape of Audits: MICs, MACs, RACs and ZPICs" co-presented with Susan Emanuel, System RAC Coordinator, Catholic Healthcare West, Phoenix, AZ; and Dawn Crump Network Director of Compliance, SSM Health Care St. Louis, Orlando, FL, HCCA's 15th Annual Compliance Institute, April 13, 2011.
"Medicaid RAC Appeals - Similarities and Differences with Medicare RAC Requirements and Processes," 5th Annual Medicare RAC Summit, Washington, D.C., March 9-11, 2011.
"Full Steam Ahead: Latest Developments in Medicare and Medicaid," co-presented with James G. Sheehan, Office of the New York State Medicaid Inspector General, American Bar Association (ABA) Emerging Issues Conference, New Orleans, LA, February 23-25, 2011.
"Medicare and Medicaid Audits: A Year in Review," American Health Lawyers Association (AHLA) Hospital and Health Systems Law Institute, Las Vegas, NV, February 11, 2011.
Please click here for a more complete listing of our attorneys' publications and speaking engagements.
Contact Us
Call us at 877-403-6048 or send us an e-mail to schedule a meeting to discuss your concerns with RACs or to discuss your other healthcare law-related needs.
