ASA August 2003 Newsletter

Your local Program Safeguard Contractor (PSC) is interested in reviewing 55 of your patient’s charts. You have been “selected” for a Medicare audit, or officially termed a Comprehensive Medical Review (CMR).

This usually occurs when a Medicare computer finds a variation in your practice compared to other providers (peers) using the same codes. Your specialty designation (anesthesiology, pain medicine or interventional pain medicine) and the specific practice profiles that the designations generate are the baseline to determine deviations. If you deviate from these profiles, a review will be considered. The code(s) to be reviewed will be indicated in your letter of notice. There is often a Medicare Profile report with your letter, which may indicate, for example, that your initial consults are 100 percent higher than threshold.

According to Lydia Rogers, Florida Medicare Director of Medical Policy, “CMR audits are never random. They are always based upon data analysis. A probe audit is used to verify that a problem exists after the data has indicated that potential. Every Medicare carrier does ongoing data analysis. This is the primary way for them to identify potential issues related to services being rendered that are medically unnecessary, up-coded, overutilized or not program benefits.”

The most serious audits are for suspected fraud. The most common type of fraud found in the Medicare system is billing for services that were never performed or furnished. The next most common fraud is related to improper business relations with others. Patient recruiters, referral networks, rental arrangements with suppliers and other creative business relations can trigger a fraud audit.

Now what do you do? Once the “shock and awe” phase passes, telephone the agent who signed your letter and ask what information is needed from you. Let him or her know that you will respond as quickly as possible. If the time limit you have been given is too short, ask for an extension; these are usually granted, especially if your notice arrives around the time of a major holiday. Do not argue or discuss the merits of the audit with the agent. Often the tone of the agent’s voice and the type of information requested will indicate the scope and direction of the audit. This call should be short and very courteous. It should, however, provide you with much valuable information.

It is advisable to contact your medical attorney and an independent practice consultant to review your charts and help you to provide responses to your CMR. With the information you have obtained from your telephone call and the requests in your CMR letter, you will be advised on the issues of concern to the PSC and your best response. This step in your response will cost you money and may take several weeks. If you have never experienced a Medicare audit, it is a very necessary step that may be extremely important in your final Medicare response. Contact these consultants immediately to schedule their reviews at the earliest possible date.

Once the consultants have reviewed your charts, determined what documentation you should supply and helped you to formulate a response, you are ready to personally review your records. Write a summary page of your care for each patient/chart reviewed. You need to explain why you performed a specific procedure and to justify the indications (medical necessity) for the procedure. Further, you need to document the level of service to support your billing. Very often, physician notes are written in a way that makes it difficult for a reviewer to follow the decision process. Help to guide your examiner by explaining what you have documented in the patient records. Highlight appropriate sections of the photocopied record. Number each page for quick reference. In your narrative, refer to the specific page and highlighted sections. This will explain and support your argument with documentation.

If you find a mistake, admit to it. You may have to pay back money, but you will demonstrate good faith and a willingness to correct your errors. This may be very helpful at the completion of the audit, and the auditors may not recommend any sanctions. The auditors do think of this review as an educational process. If you accept their desire to “educate” doctors as to the “correct” way to bill the Medicare system, you will approach this process with an attitude allowing you to better interact with the auditors.

When you submit your files and summaries to the PSC, include a cover letter. Here you have the opportunity to explain why you feel you have billed the reviewed codes correctly. If you have a Compliance Plan in effect, reference to your plan will demonstrate your efforts and willingness to be in compliance with the Medicare program. If you do not have a compliance plan, you should institute one in your practice immediately, before you have a Medicare audit.

The PSC response to your practice audit may take weeks or months. The response usually takes the form of a letter explaining its determination. There will often be a dollar amount that the PSC feels you owe back to the Medicare system. If you do not agree with the conclusion, you may file an appeal. Otherwise, you can agree to pay the dollar amount and accept any sanctions the PSC suggests. Frequently, the PSC requires audited physicians to file paper Medicare claims for certain Current Procedural Terminology™ codes for a specific period of time. This is the PSC’s way to observe you closely and be certain that you have been “educated” as to the correct method of billing Medicare. If you file those codes electronically, they will be rejected. It is important to review your determination with your attorney.

Medicare audits are becoming more common, especially in pain medicine practices. If you are audited, do ask for expert legal and billing assistance. The auditors are generally fair, but they do have the authority to negatively affect your practice and can restrict your ability to bill the Medicare system. The best defense for an audit begins with good billing policies. Do not wait for an audit notice before you institute a practice Compliance Plan. Your Compliance Plan should be reviewed by your attorney and should include an initial audit by an independent practice consultant. You, the physician, need to be actively involved in your billing process and must understand and keep current with the rules Medicare has imposed. Remember, the audit and any sanctions imposed do affect your practice and your ability to bill the Medicare system.

Phillip N. Fyman, M.D., is Co-Medical Director, Comprehensive Pain Management Associates, Jericho, New York.

Lawrence S. Gorfine, M.D., is Medical Director, Southern Pain Institute, Lake Worth, Florida.

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