Insights by Engage

There are a couple of powerful auditors looking at fraud, waste, and abuse in the healthcare arena with whom you hope to never have the pleasure of interacting. One is the Health and Human Services (HHS) Office of Inspector General (OIG). It is the largest inspector general’s office in the Federal Government and the majority of their resources and activities are focused upon the Medicare and Medicaid programs. The OIG operates under a Work Plan (OIG Work Plan). The Work Plan, which is updated monthly, advises the public about various projects including OIG audits and evaluations that are underway or planned to be addressed during the fiscal year and beyond by OIG's Office of Audit Services and Office of Evaluation and Inspections. Of course, those audits and evaluations could include time consuming activities on the part of providers and suppliers.

Published on the RAC Monitor Site on December 1^st  2020, written by Steven Greenspan JD, LLM.

And be sure to check out  Monitor Mondays on Monday 6th for a live interview with Dr. Robert Glenn.

The Medicare Program Integrity Manual (MPIM)(Pub. 100-08) is a 15-chapter manual addressing all sorts of behavior by the CMS contractors charged with protecting the Medicare Trust Fund. Chapter 3, entitled “Verifying Potential Errors and Taking Corrective Actions” (MPIM Chapter 3) has set forth the following as one of its goals:

The Centers for Medicare and Medicaid Services (CMS) requires documentation to support coverage and payment of services provided to Medicare beneficiaries. These requirements stem directly from Title XVIII of the Social Security Act (Act), Section 1833(e):

A provider or supplier (or their representative) can utilize the Medicare Appeals Process (Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B)). However, in order for an appeal to be available, you must first file a claim and have that claim denied completely or partially. This is called the initial determination. An example of a partially denied claim could be that you coded a claim, and the Medicare Administrative Contractor (MAC) changed the coding and now you will be receiving less reimbursement. Alternatively, you could have submitted a claim, been paid, and then your claim is audited and then denied. This would usually allow you to utilize the appeals process as well. This document will examine the first three (3) levels of the appeals process as most providers and suppliers only utilize these levels. Utilizing a representative that understands the complex process is often in your best interest.