5 Common Errors During RAC, MAC and ZPIC Audits |
Posted: December 11, 2017 |
5 Common Errors During RAC, MAC and ZPIC AuditsHealth care providers that bill Medicare for reimbursements are under constant scrutiny. In addition to facing investigations conducted by the Centers for Medicare and Medicaid Services (CMS), the Drug Enforcement Administration (DEA) and various other federal agencies, health care providers are also subject to audits by private contractors working for CMS. These contractors, including Recovery Audit Contractors (RACs), Medicare Administrative Contractors (MACs) and Zone Program Integrity Contractors (ZPICs) operate on a fee-for-service basis. This means, in part, that they get paid for uncovering overpayments from Medicare. When a RAC, MAC or ZPIC determines that a provider has overbilled CMS, it can demand recoupments on behalf of the government, and providers who fail to pay (or file a timely appeal) can face fines, interest and other penalties. Common Mistakes Resulting Unfavorable RAC, MAC and ZPIC Audit DeterminationsProviders facing RAC, MAC and ZPIC audits need experienced legal representation. Mistakes during the process are common; and, while there is an appeals process for unfavorable audit determinations, providers should seek to address auditors’ mistakes proactively whenever possible. The following are all common examples of mistakes that can lead to unjustified demands for recoupment, and which can be effectively addressed with the help of a knowledgeable health care fraud defense attorney: 1. Relying on Inapplicable Medicare Billing StandardsIn some cases, auditors will attempt to apply current Medicare regulations to past billings that were governed by different standards. In other cases, they will apply outdated standards to recent billings. Neither is justifiable, and both are grounds for providers to dispute auditors’ conclusions. 2. Inaccurately Interpreting Medicare Billing StandardsEven when auditors identify the correct billing standards, they may still apply or interpret them incorrectly. An attorney who is knowledgeable about the Medicare billing system will be able to spot these types of errors and address them appropriately. 3. Inaccurately Interpreting Providers’ Billing RecordsIn addition to misinterpreting Medicare billing standards, it is common for auditors to misinterpret providers’ billing records as well. 4. Using Flawed Auditing MethodologiesAuditing thousands (or tens of thousands) of patient billing records is a complex process, and it requires expert use of sophisticated sampling and statistical methods within the context of the Medicare billing regime. When RAC, MAC and ZPIC auditors rely on flawed methodologies, their entire body of findings may be unreliable. 5. Seeking Recoupments Outside of the Contractor’s Scope of AuthorityRACs, MACs and ZPICs operate within the confines of federal law and their contracts with CMS. While they have broad powers to conduct audits and seek recoupments on behalf of the government, their authority only extends so far. When audit contractors exceed their authority, health care providers are not required to voluntarily comply. Contact the Miami Federal Health Care Defense Attorneys at Stumphauzer & SlomanIf your medical practice or health care business is being audited, our firm can help protect you against a flawed determination of liability. To schedule a confidential consultation with one of our experienced attorneys, please call (305) 371-9686 or inquire online today.
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