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Be on the Lookout

August 2, 2023

We always said it was too good to be true, and it was. COVID payer actions are increasing. Two common “surprises” to many medical practices, laboratories and medical specialties have recently been: (a) the surprise inspections conducted by the Centers for Medicare and Medicaid Services (CMS), and (b) the equivalent of Medicare audits happening beyond just Medicare.

A Knock at the Door

Clients continue to face surprise inspections by Medicare’s intermediaries to see if labs are truly labs. Coming out of COVID, when so many pop-up labs came onto the scene, Medicare is now being very careful about validating the actual existence of labs—clinical, molecular, anatomic and so on. It happens in many different ways, ostensibly under the guise of revalidation for Medicare, and is more recently tied to the confirmation of CLIA status. All of that happens with either no notice or minimal preparation. The good news is that most of these recent inspections have been cursory, confirming that Medicare is concerned that some of its payments may not be going to legitimate entities.

Audits are the backbone of Medicare’s “gotcha” strategy of collecting on payments already made to providers. Frequently conducted by RAC (recovery audit contractor) auditors, these reviews have been a longstanding practice for Medicare and often involves a request for providers to send records pertaining to a long list of Medicare beneficiaries. The more challenging situation is where the provider is sent a list with a notice of a time period in which the auditors will arrive to review documents. (These days, this may be more remotely conducted.)  They are keen to get their money back, which could be done by way of recoupment. One has to wonder if the audits in general—but onsite audits more specifically—are nothing more than a fishing expedition to uncover broader issues. As the old adage goes, not everything is as it appears.

Reasonable Preparations

Providers would do well to be careful in all their testing and billing pursuits. And if anyone billed for COVID testing in any significant volume, they should brace themselves for audits, investigations, recoupments and potential deep dives on a patient-by-patient basis. Medicare has a history of going after its money when it believes it has due cause.

There are two final notes of caution:

  • Don’t forget whistleblowers roam the villages in which you operate and the halls in which you do testing. Whistleblowers are Medicare’s number one way to learn of questionable practices, and they act with interest more and more frequently.
  • Audits and actions are by no means limited to CMS and its watchdog agency, the Office of Inspector General (OIG). State Medicaid entities are increasingly active. And do not discount the actions of commercial payers who want to recoup anything they can find. Sometimes, the purview of commercial payers is broader and more intense since they don’t necessarily play by the government’s rules of engagement—which can be statutorily restricted or controlled. Commercial payers have their own play books, and they act accordingly.

To sum up, expect that knock at the door. If you’re aware now that review requests are on their way, you are far more likely to have a practice that places a premium on compliance—at least on a going forward basis. The natural outgrowth of this outlook should be a provider group that is able to withstand the scrutiny with increasing confidence. 

With best wishes,

Michael Ferrie
President—Laboratory & Pathology

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