Is Medicare Dialing Back Improper Payment Audits?


Medicare claims audits have long been the bane of physicians, often entailing exhaustive medical records requests and increased paperwork. But things may be changing, courtesy of a recent announcement from the Centers for Medicare & Medicaid Services about the nationwide launch of a streamlined audit process for Medicare Administrative Contractors.

The Targeted Probe and Educate (TPE) audits will review claims for services that have the highest risk of improper payments and will focus on providers with high claims error rates. The targeted approach will involve reviewing fewer claims per provider and should ease administrative burdens, the CMS said.

The nationwide rollout supports the Trump administration’s goal of reducing provider burdens, Ellyn Sternfield, a health-care attorney with Mintz, Levin, Cohn, Ferris, Glovsky and Popeo PC, told me.

It could also lead to a reduction in the number of Medicare claims appeals, Sternfield said. The audits are designed to educate providers on proper claims billing behavior, rather than punish them for improper payments.

The TPE audits were initially rolled out in a June 2016 pilot program in one MAC jurisdiction, and include a claims review component, known as the probe, that is smaller than in traditional MAC audits. Once the claims review portion is over, the MAC meets with the individual providers to educate them on ways to avoid improper payments.

Targeting the audits should be more persuasive in encouraging better billing habits than auditing all providers in an industry sector billing for a particular code, Judith Waltz, a health-care attorney with Foley & Lardner LLP, told me.

Read my full article here.

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