A Resource For Legitimate Practitioners

The Problem

If you've received a "request" for medical records from from an outfit you never heard of, wanting to determine if claims you submitted to Medicare were correctly paid, you probably had no idea what was happening. You probably submitted the records because the letter made it clear you were required to do so or your claims would be deemed "overpaid" for lack of supporting documentation and your money would be "recouped."

No problem, right? Why wouldn't you provide the records...you have nothing to hide or feel uneasy about. So you sent them. If you're experience was typical, 60 days later you received another letter from the same outfit, this one demanding a large sum of money, supposed an "overpayment" for the services you provided. You didn't know what hit you and you never saw it coming. Who are these people and why are they doing this to us?

Background

CMS pursues strategies to “detect and deter fraud and abuse” through its Benefit Integrity Program. In 2006, responsibility for this function was transferred from the fraud and abuse units of Medicare’s fiscal intermediaries (FIs) to entities known as Program Safeguard Contractors (PSCs).

The PSCs are large corporate contractors feeding at the government trough. They are empowered to conduct "proactive data analysis" of payment claims looking for practice patterns they consider unusual. Once they identify a practice as an “outlier,” they're supposed to undertake a more detailed analysis of the practice to determine if there are "legitimate" reasons for the unusual pattern. A group that specializes in the care of complex elderly patients, for example, would be expected to bill higher levels of service.

If there is no "legitimate" explanation, the PSCs are supposed to undertake educational initiatives and other remedial steps to correct provider behavior. They are also supposed to “recovery” money that was paid incorrectly. The auditor would "find" a payment incorrect if, for example, the documentation in the medical record did not support the level of service billed, in which case the claim would be "downcoded;" if the service were deemed not medically necessary, the claim would be denied and the entire payment "recouped."

Nobody questions the importance of protecting the Medicare Trust Fund or rooting out fraud and abuse. The problem is that the PSCs are not playing by the rules. Fueled by strong financial incentives, the PSCs disregard CMS requirements that afford due process protection to providers. As a result, their findings are often without merit and largely overturned on appeal to an administrative law judge (ALJ). Few physicians have the will or resources to fight all the way to that level, and therefore acquiesce to the PSC's demands. But that only spurs further attacks: you're sees as an easy mark, assumed to be guilty or unwilling to fight back.

Many providers are being caught in the wide net cast by these rogue contractors. Physicians are being demoralized and legitimate practices are being damaged or even destroyed. CMS seems to believe the PSCs are accomplishing something as long as they "recover" significant sums of money early in the audit, regardless of how the process is conducted, what happens on appeal, or the collateral damage that occurs along the way.

The Solution: Fight Back – Acquiescence Is Not An Option!

Legitimate practitioner who have reasonably good documentation can and must defend themselves! You can receive a fair hearing when your case comes before a judge. Money that was improperly taken away from you will be returned, with accrued interest at more than 12%.

If you’re a legitimate practitioner but your documentation does not adequately support your claims, we will

• help you get extricate yourself from the audit as quickly and inexpensively as possible, and
• teach you to document in a way that should “bullet-proof” your claims from future audits.
  

You should understand up front that this whole process is extremely aggravating, time consuming and expensive. The PSCs are big corporations with deep pockets. To fight them effectively you must hire experienced, highly specialized experts who are in high demand and short supply. But acquiescence is not an option. If you don’t defend yourself, the contractors will assume you're an easy, too guilty or scared to defend yourself. They will keep coming after you.

Who We Are And What We Can Do To Help

You have to get MAD before you can get even. We’re an audit defense team of

• physicians with in-depth clinical, business and practice management experience who have won audit battles and know how to document medical records in a way that "immunizes" them from attack;
• documentation consultants with years of experience auditing medical records, defending physicians through the audit process, and teaching them how to code for maximum reimbursement and minimal risk of “recovery;” and
• health care attorneys with specific knowledge and experience with audits and compliance issues.

The captain of your audit defense team is Alan Kronhaus, M.D.. He has hand-picked each member of the team for their special skills and commitment, which he brings to bear on the process only as needed. If you have the time and inclination to fight on your own, we will help educate and guide you so you can do as much as possible as inexpensively as possible. Alternatively, we can carry the load completely in your behalf, freeing you to run your practice with minimal distractions or disruption.

Contact Us Today

Please feel free to call to discuss your situation. An initial phone consultation of up to a half hour is free, and may provide you with enough information for you to proceed on your own. If you decide to engage our services, we’ll explain our fee structure and, if possible, estimate what the entire engagement might cost, depending on where you are in the audit process and what you’ll require from us. We are always willing to work with experts you’ve already hired to help you.

Phone: 919-932-5700 and ask for Dr. Kronhaus, or

Email: kronhaus@medicalauditdefense.com