According to Medicare, more than $6.5 billion in claims are now tied up in pending appeals. The backlog, in part can be attributed to wide-spread and often aggressive audits by Medicare Administrative Contractors (MACs). A “missing documentation” error can be as simple as an illegible/missing signature. For example, earlier this year, CGS – the Medicare contractor for Kentucky – implemented a rule that required all EHRs to be signed and closed by the physician within two days of when the service was provided. If the two day requirement was not met it allowed the reviewer to recoup Medicare funds.
KMA was quick to point out:
- The Centers for Medicare and Medicaid Services does not provide exact timeframes for signing and closing the EHR.
- The overarching decision regarding claims review is the medical necessity of the visit and documentation to support the visit.
An appeal is one of the few legal remedies available to physicians when it comes to audits and KMA has successfully helped members appeal adverse audit decisions while bringing attention to audit tactics that sometimes don’t follow standard CPT coding guidelines or established Medicare or Medicaid regulations.
The current Medicare appeals backlog is so large that it can take years to appeal an audit, but physicians and hospitals are successful in more than half of the claims appealed.
To address the appeals backlog Medicare is looking for ways to reduce the administrative burden for physicians with a new audit strategy.
The new strategy, called Targeted Probe and Educate (TPE), will only perform audits on specific providers (not necessarily physicians) and select claims for services or items “that pose the greatest financial risk to the Medicare trust fund and/or those that have a higher national error rate,” CMS said.
Data analyses will provide information on the highest claim error rates and/or billing practices that differ significantly from peers.
While this change will not eliminate audits, it will result in fewer audits, and claim reviews (between 20 -40 claims per service), while providing the physicians with an opportunity to correct any billing or coding problems.
