Practice Brief
Federal Government Audit Entities
ACRON YM
CERT
DOJ
HEAT
MAC
Medicaid RAC
MFCU
MIC
MIP
OIG
OMIG
PERM
RAC
ZPIC
PROGRAM NAME
Comprehensive Error Rate Testing Program
Department of Justice
Health Care Fraud Prevention and Enforcement Action Team
Medicare Administrative Contractor
State Medicaid Recovery Audit Contractor
Medicaid Fraud Control Unit
Medicaid Integrity Contractor
Medicaid Integrity Program
Office of Inspector General
State Office of Medicaid Inspector General
Payment Error Rate Measurement Program
Medicare Recovery Audit Contractor
Zone Program Integrity Contractor
determine the overpayment amount.
Organizations should carefully review auditor requests for the
possible extrapolation method because these audits have significant financial risk. The auditor may review only five to 10 records but based on the extrapolation method take back money
on more than 100 records because that is the number of patient
records with that specific DRG. For example, if the organization
sees that the record request will be extrapolated, it can immediately review the five records requested. If the organization finds
that the code assignment is incorrect, it can prepare financially
for the loss of revenue.
The auditor is required to send the results of the review in a
demand letter that outlines the method used and overpayment
amount. These rulings can be appealed through the auditor’s
appeal process.
Impact of the Query Process
An effective query process can help organizations and providers
submit claims that best describe the services provided. Queries
can be applied concurrently, pre-bill, or post-bill. Many organizations struggle to understand the impact a post-bill query
and the impact its subsequent payment rebill has on the audit
process.
A post-bill query is appropriate after an audit when an error
was found and clinical clarification is required. All overpayments should be rebilled regardless of the length of time since
initially billed. 1
The Centers for Medicare and Medicaid Services (CMS) has
reminded providers to ensure that “any information that affects
the billed services and is acquired after physician documenta-
tion is complete…be added to the existing documentation in ac-
cordance with accepted standards for amending medical record
documentation.” 2
Audit Operations
CMS considers the compliance officer role to be crucial in reducing the number of improper payments. As a result, the
Hospital Payment Monitoring Program (HPMP), formerly the
Payment Error Prevention Program, developed the HPMP Compliance Workbook to provide guidance and tools for organizations seeking to strengthen their compliance programs and help
reduce payment errors.
The guidance includes documents related to clinical laboratories, home health agencies, hospices, and nursing homes
that should be referenced if those services are provided. It is
available at www.metastar.com/Web/Portals/0/Documents/
HPMP/HPMP-ComplianceWorkbook.pdf.
An organization’s compliance program should go beyond inpatient claims to encompass other government audits because
an organization’s risk is based on high-volume or problem areas
as well as the variety of services or settings it provides.†
