OK, let's be straight about this: There is no big secret to getting paid by Medicare. Just put an AT modifier after a 98940, 98941 or 98942 in blank 24D on the CMS-1500 form and Medicare will pay you.Of course, getting paid is not the problem; keeping the money after you are paid is the problem. Medicare continues to increase its efforts to review your records and recover money from "overpayments." From Medicare's perspective, an overpayment is payment for any service that is not documented as medically necessary in the patient chart. In addition to overpayments, Medicare is looking for two other problems: abuse and fraud, defined as follows:
"Abuse - Billing Medicare for services that are not covered or are not correctly coded. Fraud - The intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and the individual makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person."1
The Centers for Medicare & Medicaid Services (CMS) and the Office of the Inspector General for Health and Human Services (OIG) continue to increase their capabilities and efforts to review your records to determine whether you have documented medical necessity. A very important point to remember is that if anyone connected with Medicare has requested patient records, then you are under review. Let's take a look at how and by whom you are reviewed.
Office of the Inspector General
The OIG is concerned with fraud. It can review everyone from individual providers to state agencies to the CMS itself. The OIG has its own auditors and inspectors, and can enter your office and review your records at any time without a search warrant. The OIG can also request and obtain the assistance of the FBI. One doctor who tried to throw an OIG inspector out of his office was fined $500,000 and then audited in great detail. If the OIG finds evidence of fraud, it can demand repayment, levy civil money penalties and refer cases to the Department of Justice for prosecution.
Centers for Medicare & Medicaid Services
The CMS uses many contractors and subcontractors to audit and review patient records. There are three types of reviews: automated reviews performed by the computer; routine reviews performed by non-medical staff; and complex medical reviews performed by licensed professionals.
Carriers and Medicare Administrative Contractors (MAC)
CMS contracts with private corporations to serve as carriers (old) and Medicare administrative contractors (MAC; new) to process and pay Medicare claims within one (or more) of the 15 jurisdictions around the country. These companies are charged by CMS with ensuring that the claims are properly coded and that only medically necessary services are paid. They accomplish this by conducting automated reviews of claims as they are processed, routine reviews and complex medical reviews.
According to CMS, "Carriers (or their contractors) can also conduct probe reviews where they examine 20-40 claims per provider for provider-specific problems. When probe reviews verify that an error exists, the Contractor classifies the severity of the problem as minor, moderate, or significant. Contractors may classify the severity of the error by determining the provider-specific error rate (number of claims paid in error), dollar amounts improperly paid, and past billing history. Contractors then use Progressive Corrective Action (PCA) to ensure that MR activities are targeted at identified problem areas and that the corrective actions imposed are appropriate for the severity of the problem."2
Comprehensive Error Rate Testing (CERT)
The Medicare Program Integrity Manual states: "The CMS developed the CERT program to produce a national Medicare fee-for-service error rate compliant with the Improper Payments Information Act. CERT randomly selects a sample of Medicare FFS claims, requests medical records from providers who submitted the claims, and reviews the claims and medical records for compliance with Medicare coverage, coding, and billing rules."3
Recovery Audit Contractors (RAC)
According to a CMS Recovery Audit Contractor (RAC) fact sheet released Oct. 6, 2008, "The Centers for Medicare & Medicaid Services (CMS) has taken the next steps in the agency's comprehensive efforts to identify improper Medicare payments and fight fraud, waste and abuse in the Medicare program by awarding contracts to four permanent Recovery Audit Contractors (RACs) designed to guard the Medicare Trust Fund.
"In the Tax Relief and Health Care Act of 2006, Congress required a permanent and national RAC program to be in place by January 1, 2010. The national RAC program is the outgrowth of a successful demonstration program that used RACs to identify Medicare overpayments and underpayments to health care providers and suppliers in California, Florida, New York, Massachusetts, South Carolina and Arizona. The demonstration resulted in over $900 million in overpayments being returned to the Medicare Trust Fund between 2005 and 2008 and nearly $38 million in underpayments returned to health care providers."4
Depending on the legal structure of the practice, the RAC can request 10, 20 or 30 records per NPI number every 45 days. Since the RAC is paid on commission, if it finds overpayments in the first batch of records it will surely be back for more every 45 days until it has reviewed every Medicare record that you have available (up to three prior years of records).
What Do I Send When Asked for Records?
Many times, when doctors receive a request for additional records from any of the above entities, they panic. Then the frustration sets in with a comment such as, "What do these people want?" The short answer is that they want sufficient documentation to prove the care billed was medically necessary. If they don't get it, they will deny the claim as medically unnecessary and either refuse to pay you or request that you refund the money you were already paid.
Requests for records can range from a request for records of a single visit to a request for records for an entire case. You will want to carefully read the request letter to determine exactly what is required. Generally, the information you send in should include the following:
- the visit notes for the visit(s) in question;
- the history, exam (or re-exam), outcome assessment questionnaires, and treatment plan from immediately before the visit(s) in question;
- the history, exam (or re-exam), outcome assessment questionnaires, and treatment plan from immediately after the visit(s) in question;
- if the range of visits is sufficiently large, the interim history, exam (or re-exam), outcome assessment questionnaires, and treatment plan;
- any discharge notes (if applicable);
- any notes explaining irregular compliance or non-compliance by the patient; and
- X-ray and/or other test reports.
Again, the key is to provide the reviewers enough information to prove medical necessity of care. Some doctors believe they should just "send everything there is" and hope for the best. This strategy holds the same risk that saying too much on the witness stand holds; by giving more than was asked for, you may open new avenues of investigation. Keep your responses to the point and answer the questions asked. Send only the records necessary to prove medical necessity for the visit(s) in question.
- Medicare Program Integrity Manual: Exhibits, Exhibit 1, Definitions.
- The Medicare Medical Review Program. CMS, Medicare Learning Network, July 2007.
- Medicare Program Integrity Manual: Chapter 12, Section 12.3.
- CMS RAC (Recovery Audit Contractors) Fact Sheet, Oct. 6, 2008.
This is part 1 of a five-part series by Dr. Short on Medicare payments and audits. Future articles will discuss additional strategies for what Dr. Short calls "increasing your MMR (Medicare Money Retention)."
Dr. Ronald Short is a certified medical compliance specialist and a certified professional coder. He has authored numerous books on Medicare including The Medicare Documentation System. He also teaches seminars on Medicare, coding, billing, documentation and compliance. You can contact him at
. More information about this and other Medicare topics is available at www.chiromedicare.net.