Viewpoint: Some providers receive a 'free pass' from auditing Medicare claims

Low-volume Medicare providers escape from having claims reviewed for accuracy under new additional documentation request limits for recovery audits, according to Kristin Walter, an opinion contributor to The Hill.

Ms. Walter, spokesperson for The Council for Medicare Integrity, outlines the new policy and her viewpoint in a recent article.

CMS in May 2016 revealed new ADR limits for the Medicare Fee-For-Service Recovery Audit Program. The policy calls for an annual baseline ADR limit of 0.5 percent of the provider's paid Medicare claims from a previous 12-month period. But CMS said it will calculate or recalculate a provider's compliance with Medicare billing rules following three 45-day ADR cycles.

Ms. Walter writes a provider's ADR limit will then be lowered if they show accurate billing and increased if they have many billing mistakes. This would be the "adjusted" ADR limit.

Overall, she described the policy as a "loophole."

This "is allowing some providers to receive a 'free pass' from auditing their claims for billing accuracy," she wrote. "For example, RACs [recovery audit contractors] currently can review 0.5 percent of a provider's claims among approximately just 26 currently approved billing issue areas. Any Medicare provider that submits fewer than 1,599 particular claims to the program per year would consistently have 0 claims audited for billing accuracy. This means that low-volume Medicare providers may not qualify to have even one claim reviewed."

Ms. Walter concluded by calling on CMS to "either set a minimum number of claims to be audited each period by provider to close the low volume loophole or consider increasing the base ADR limit across the board for all provider types."

 

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