RAC (Recovery Audit Contractor) / MAC (Medicare Administrative Contractor)
With the introduction of the Recovery Audit Contractor (RAC) and Medicare Administrative Contractor (MAC) programs hospitals are confronted with demands to return alleged overpayments as well as the threat of denial of payments up front. Any claim can now be reviewed at any time and the MACs can even initiate 100 percent prepayment review of claims should they determine that a hospital’s coding and billing compliance rises to the level of a “serious problem.” While the intent of both programs is to preserve the integrity of the Medicare trust fund, the contingency fee structure under which the contractors work skews the focus of the program away from preservation through educating providers and solely toward denying as many payments as possible, something healthcare providers know all too well.
When denied claims are received by F&W, an Attorney or Senior Reimbursement Analyst will review the claims to determine the appropriate course of action. The claims, applicable due dates for any necessary appeals and strategy for pursuing the claims will be entered into Quantum Appeals, our proprietary claims management software. If the appeal or claim analysis requires clinical expertise, the case is sent for review by one of the clinicians on our team (physician or registered nurse).
Once an appeal has been drafted, a Senior Attorney or Senior Reimbursement Analyst reviews the appeal and, if necessary, adds Federal, State, or contractual language to the appeal. Once approved, the appeal is sent and the case is assigned to a Recovery Specialist who follows-up to ensure that the appeal is received and addressed by the Insurer in a timely manner. Each case is continually audited by an Attorney or Reimbursement Analyst to ensure that the appeal process is proceeding appropriately. In the event of an unfavorable decision, F&W will continue appealing meritorious cases through the appropriate levels.
ZPIC (Zone Program Integrity Contractor)/ OIG (Office of the Inspector General)
Hospitals and healthcare systems are aware that the government has made healthcare fraud and abuse enforcement a top priority. Audits by the Zone Program Integrity Contactors (ZPICs) and the Office of the Inspector General (OIG) focus on potential fraud and abuse for all Medicare claims. ZPICs hold the power to refer cases to law enforcement for criminal prosecution of the entity as well as individuals involved. Entities and individuals can be charged in civil litigation under the False Claims Act or face the imposition of a Civil Monetary Penalty (CMP) or other sanctions. F&W’s experience with OIG and ZPIC investigations has also given us a distinct understanding of the issues surrounding potential fraud and when a claim should be considered for obligatory reporting.
Once the documentation request is received from the contractor, Fotheringill & Wade works with the provider to ensure that any and all documentation is provided in an easy to reference, organized fashion for the contractor to review. F&W reviews the available documentation pertaining to the audit and also provides a summary of findings explaining pertinent positive and negative documentation. This easy to review compilation can aid in preventing claim denials and other associated penalties.
Should the claim be denied after review, F&W will review all clinical documentation and appeal the denial decision, where appropriate. F&W’s staff has years of experience with Medicare appeals and boasts successful results at all levels of appeal. Should the claim remain denied, an attorney from F&W, specifically trained in Medicare hearings, will argue the provider’s claim in front of an Administrative Law Judge.
CERT (Comprehensive Error Rate Testing)
The Centers for Medicare & Medicaid Services (CMS) uses the Comprehensive Error Rate Testing (CERT) program to measure improper payments that are not considered fraud but which may not meet Medicare requirements. Utilizing random sampling, the target of the CERT program are errors made by fiscal intermediaries (FIs), Medicare Administrative Contractors (MACs) or other carriers when paying providers’ Medicare claims.
While a hospital or health system may not be the specific target of a CERT, providers are affected because they are responsible for complying with medical records requests for claims being reviewed by the CERT. And, ultimately, if the CERT uncovers coding or billing errors, the CERT will take action to recoup Medicare payments from the hospital.
Complying with coding and billing rules associated with the CERT program have become increasingly challenging and time consuming. CERT errors are typically not because the services were not medically necessary. Rather, CERT errors generally indicate a failure to submit documentation, or a lack of documentation to support the medical necessity. F&W has an experienced team of experts well versed in the CERT program. Our specialists in coding, legal, medical and administrative issues related to Medicare payment denials can handle all aspects of CERT and are available to supplement the efforts of your internal team.
QIO (Quality Improvement Organization)
F&W has extensive experience assisting hospitals and healthcare systems counter the subjective determinations of the Quality Improvement Organizations, the contractor’s tasked with the responsibility of improving the effectiveness, efficiency, economy and quality of services delivered to Medicare beneficiaries. Our highly skilled team of attorneys, physicians, registered nurses, coders and recovery specialists will work together to closely examines medical records, identify clinical evidence needed to support a claim and craft a compelling argument to overturn the QIO determination. We maintain a high success rate recovering denied and underpaid claims based on the subjective determinations after the fact.
Maryland Medical Assistance Program
We understand the complexities of COMAR billing regulations, including the requirements surrounding the administrative billing process and birth claims, which can both be particularly problematic for providers. We have an extensive knowledge of the Maryland Medicaid appeals process, and utilize our firm’s on-site clinical staff to appeal utilization review/medical necessity denials by Delmarva and to request administrative review by the Department of Health and Mental Hygiene when necessary. Our firm is well versed in the administrative hearing process and can represent the provider at hearing if needed.
Similar to Medicare, TRICARE, utilizes regional contractors to process claims. However, unlike Medicare, which provides five levels of appeal, the TRICARE appeals process only provides three levels of review for denied claims. Furthermore, the type of review available varies depending on whether the denial of benefits involves a medical necessity determination, factual determination, provider authorization, provider sanction, and/or a dual-eligibility determination.
In all TRICARE appeals, the burden of proof is on the appealing party to establish by substantial evidence the appealing party’s right to payment. With limited opportunities to make your case, providers must maximize each available opportunity. We understand the TRICARE appeals process. Whether you have received a denial based on medical necessity, factual determination, provider authorization or a provider liability determination, our team of attorneys, physicians, registered nurses, coders and recovery specialists will work together to craft compelling arguments to overturn your denials.