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EE CX UE TC I U V T E I VS EU M S M U A MR MY A R Y OBJECTIVES To determine: (1) the extent to which stand-alone Medicare prescription drug plan (PDP) sponsor contracts were audited between 2006 and 2009, (2) the extent to which these audits identified problems, and (3) whether the Centers for Medicare & Medicaid Services (CMS) had evidence to show that corrective actions were taken to resolve these problems. BACKGROUND CMS contracts with private companies, known as plan sponsors, to offe.
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Mdbg FAQ
Recovery Auditors who choose to review a provider using their Adjusted ADR limit must review under a 6-month look-back period, based on the claim paid date. Recovery Auditors who choose to review a provider using their 0.5% baseline annual ADR limit may review under a 3-year look-back period, per CMS approval.
While they focus on educating Medicare providers about proper billing techniques, the threat of legal action looms in the background if progress is not made. Healthcare providers who fail TPE audits can be excluded from the Medicare program and can even be referred to law enforcement for a Medicare fraud investigation.
Comprehensive Error Rate Testing (CERT) Audits The CERT audit is a post-payment audit for Medicare Part A, Part B, and DMEPOS claims that CMS uses to estimate Medicare FFS improper payments. Unlike the other audit types discussed in this alert, CERT audits review a random sample of Medicare FFS claims.
Types of Contractors That Conduct Audits Medicare Administrative Contractors (MACs) regionally manage policy and payment related to reimbursement. The MAC scope of work includes using data from other contractors to target improper payment and vulnerabilities.
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed. Focus: Medicaid over- and underpayments Medicaid RACs identify Medicaid fee-for- service claims that contain improper payments.
Types of Medicare Audits The RAC audits were developed in ance with the Medicare Modernization Act of 2003. The program reclaims money by reviewing fee-for-service (FFA) claims – a process that has come to be known as a “clawback.” The RAC audits essentially divide the country into four regions.
Generally, a 5-year look back period from date of audit engagement letter. 3-year look back period from date of claim payment (consistent with Medicare RAC audit period), unless RAC receives approval from the State, and the State requests and is granted an exception from CMS.
Failure to recertify the plan of care when appropriate. Noncompliance with frequency/duration rules indicated within Local Coverage Decision (LCD) Insufficient documentation. Post-denial modification to documentation.
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