Compliance, the “New Alphabet Soup” of Auditing Agencies

Are you into the “healthcare compliance & HIPAA” world?  Are you dealing with physicians and “chart audits”?

There are now so many agencies out there, designed to review, audit, evaluate, assess and, if called for, prosecute providers, who are not in “compliance”.  In our recent experience, a dramatic increase in auditing activities  – at least in certain areas of the country, has become an ongoing issue with many medical groups.

Why is it more critical than ever that providers be proactive, establishing an up-to-date Compliance Program? Many providers have started to experience an increase in auditing by Palmetto or other agencies.  There are more agencies out there, well funded and being rolled out across the country, not just aiming at hospitals, like in the initial (RAC) pilot projects, but more and more aimed at physician providers.

As part of the HITECH Act provisions in the American Recovery and Reinvestment Act, more resources are being made available to auditors and investigators to investigate fraud and abuse in the Medicare and Medicaid programs.

Some of these efforts are new, and some are consolidations of previous efforts.  All represent increased exposure for healthcare providers to additional audits and claims by the government for reimbursement of previous payments – or even claims of fraud or abuse.

The  New  “Alphabet  Soup”  Of Auditing  Agencies

RACs – Recovery Audit Contractors

After a “successful” pilot project in three states, Congress has authorized expansion of the program nationwide.  The geographic areas cover seven zones across the US. ACs are paid on a contingency basis, so the incentive is to find overpayments! RACs will perform “automated reviews”. These are based on statistical sampling of claims submitted to Medicare, and can also ask for considerable quantities of medical records each quarter.  Both types of reviews can result in claims of overpayments, with amounts extrapolated to a provider’s entire claims universe – resulting in large amounts demanded as repayment.

ZPICs – Zone Program Integrity Contractors
A consolidation of the previous Program Safeguard Contractors and the Medicare Drug Integrity Contractors, the focus is on finding fraud through pre-and post-payment review, and data analysis, including extrapolating results to all of a provider’s claims for purposes of demanding repayment.

MICs – Medicaid Integrity Contractors
MICs are a new CMS program designed to find fraud by Medicaid providers.  Suspected cases are referred to the OIG for prosecution or sanctions.

MFCUs – Medicaid Fraud Control Units
MFCUs are usually based in state Attorney General offices, and are designed to investigate and prosecute cases of Medicaid fraud and instances of patient abuse or neglect.  Providers can also be sanctioned or excluded from Medicaid or Medicare.

There are also FERA, Fraud Enforcement Act of 2009, and HEAT, Healthcare Fraud Prevention and Enforcement Action Team.

For many years, most industries have monitored their own compliance with safety and environmental regulations.  However, in our era  of EMR systems, electronic transmission of insurance claims, emails, cell phones and faxes, the word “compliance” has taken on a new meaning in the healthcare industry.

The “roll out” of some agencies is delayed in some areas of the country, especially for medical groups & physician organizations, but the increased activities of what was traditionally called the “intermediaries” is a good example of what likely is going to happen, just more, more intense, and more often.   Here a two page check list how to respond and what to do in case of audit on .

We like to know about your experience with any one of these agencies or other type of audit activities in your physician group.

When you need proven expertise and performance

Dr. Gunter G. Fuchs

Dr. Gunter G. Fuchs has over 30 years of clinical, administrative, consulting, acute care operations, and strategic planning experience in domestic and international healthcare.

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