OIG’s Audit found Medicare Contractors Were Not Consistent in How They Reviewed Extrapolated Overpayments in the Provider Appeals Process

oig audit

oig auditBy: Karina P. Gonzalez

When an overpayment is identified in Medicare Part A or B claims, providers can contest the overpayment amount by using the Medicare administrative appeals process.  Because of the large difference between overpayment amount in a sample from an extrapolated amount, the OIG states that it is critical for the review process during an appeal to be fair and consistent. In the first and second levels of Medicare appeals (redetermination and reconsideration) extrapolated overpayments are reviewed by MAC (Medicare Administrative Contractors) and by QICs (Qualified Independent Contractors).

The OIG audit was to make sure that the MACs and the QICs reviewed the appealed extrapolated overpayments consistently and in compliance with CMS requirements.

What OIG found was that CMS did not always provide sufficient guidance and oversight to ensure that these reviews were performed in a consistent manner.  The most significant inconsistency identified was the use of a type of simulation testing that was performed only by a subset of contractors.  The test was associated with at least $42 million in extrapolated overpayments that were overturned in fiscal years 2017 and 2018.Continue reading

CMS Rolls Out a General Provider Telehealth and Telemedicine Tool Kit

Information from CMS for medical providers on telehealth and telemedicine

Information from CMS for medical providers on telehealth and telemedicineBy: Susan St. John

CMS has rolled out a telehealth/telemedicine tool kit to assist medical professionals with health care delivery during the current COVID-19 public health emergency.

The toolkit contains information and links concerning:

 

  • 1135 Waivers – allows the Secretary of HHS to temporarily waive or modify certain Medicare, Medicaid, and Children’s Health Insurance Program (CHIP) requirements to ensure sufficient health care services and items are available to meet the needs of individuals enrolled in Social Security Act programs during the emergency and that providers who provide services in good faith can be reimbursed and exempted from sanctions (provided there is no determination of fraud and abuse). 1135 waiver or modifications include:
    • Conditions of participation and other certification requirements;
    • Program participation and similar requirements;
    • Preapproval requirements;
    • State licensing requirements where services are rendered as long as the provider has equivalent licensing in another State (for Medicare, Medicaid, CHIP reimbursement only; State licensing still controls whether a non-Federal provider may provide services in a state he/she is not licensed in);
    • EMTALA sanctions for redirection for medical screening, as long as redirection is not the result of discrimination on the basis of a patient’s source of payment or ability to pay;
    • Stark self-referral sanctions;
    • Adjustment (not waiver) to performance deadlines and timetables;
    • Limitations on payment to permit Medicare enrollees to use out of network providers in an emergency situation.

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