Editor's Note

Chasing Audits: A True Story

Sometimes it seems as if human beings can adapt to almost anything — the debilitating winter that affected most of the country being the latest example.

But if adaptability is our super-power, then inconsistency is our Kryptonite. We can adapt to almost anything. But we have to know what to adapt to.

Recently, a provider — whose identity I’m keeping private — gave an example of how unorganized Medicare’s audit operations are: “Even after the RAC auditor pulls back an audit, the Redetermination people and Reconsideration people can continue to pursue it.”

March 15, 2013 (fictitious date, but the times elapsed are factual): The provider receives a request from a Recovery Audit Contractor (RAC). Within a month, the provider faxes to the RAC that nearly two dozen pages of documentation have been supplied.

May 11: RAC sends a letter stating it has not received additional documentation and will instruct the DME MAC to reverse payment for the affected claim.

May 30: DME MAC sends provider a letter: Original payments have been reversed, and the provider now owes the DME MAC approximately $3,500.

June 30: The provider sends a Redetermination request with the documents sent in response to the first additional documentation order.

July 5: RAC informs the provider that it is no longer pursuing the claim and is instructing the DME MAC to stop collection attempts.

“At this point, I think we’re done,” the provider says.

August 15: The provider hears from Redetermination that an “Unfavorable” decision has been made. “I thought that this must be a timing issue that the [RAC] information had not yet reached them,” the provider said.

August 24: Reconsideration request sent to Qualified Independent Contractor (QIC), “which I based upon the audit/claim being retracted by [the RAC on July 5],” the provider said.

Sept. 6: QIC acknowledges receiving the Reconsideration request.

Sept. 10: DME MAC says it has “received a valid Reconsideration request, the debt has been fully satisfied, and no further action is required.”

Oct. 28: QIC says the Reconsideration decision is Unfavorable; the provider owes $3,500.

The provider called a QIC customer service rep (CSR), who said the people at Reconsideration had no way of knowing that the RAC or the DME MAC had decided not to pursue the audit or that it had already been satisfied. Apparently, the burden is on the provider to say, “Hey, QIC: Stop everything, because the DME MAC has stopped chasing this claim.” Apparently, Centers for Medicare & Medicaid Services (CMS) contractors don’t communicate with each other, and CMS isn’t relaying messages, either.

When the provider pointed out that providers don’t know they’re supposed to play traffic cop in these scenarios, the super-helpful CSR told the provider to appeal to the Administrative Law Judge. The CSR also hadn’t been told that late last year, the Office of Medicare Hearings & Appeals stopped accepting cases like this for the foreseeable future because of a backlog totaling hundreds of thousands of cases. The provider broke this news to the CSR.

“Our supervisor didn’t tell us that yet,” the CSR told the provider.

I have a feeling that those of you left in the industry are the honest ones — trying to do right by your customers, trying to play by the rules. And humans have an amazing ability to adapt. But we can’t hit a perpetually moving target. CMS, if you truly want a partner in this journey, we’re in. But first, talk amongst your various contractors and get on the same page. Then let us know.

This article originally appeared in the March 2014 issue of Mobility Management.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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