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You Only THINK You Aren’t Being Audited by Medicare… Check Again

by | Sep 9, 2024 | Healthcare Payment Policy, Medicare Audits | 0 comments

You Only THINK You Aren’t Being Audited by Medicare… Check Again

I have been posting warnings about the increase in Medicare audits, especially for CTPs/skin subs and hyperbaric oxygen therapy for many years. Because everyone was being audited, I KNEW that my hospital-based outpatient department (HOPD) was going to be audited. The question was not “if” but “when.” I started calling the medical records department once a month to see who was calling for records on wound center patients, and kept being told there were no calls for records. Then, out of the blue, my hospital regional compliance team, which works downtown rather than at my suburban hospital – called to tell me that my department had failed the first round of a Targeted Probe and Educate (TPE) audit, and could I help them understand what was needed for round two? I had been asking the wrong people. I clearly had no idea how my hospital was notified of audits and who responded to them. I felt like an idiot.

My department director and I drove downtown to meet with the compliance team and explained to them what parts of the chart needed to be provided to correctly respond to the TPE. The typical mistake (which they had made) was to send only the records for the date of service, and not the entire chart which documented the medical necessity of the treatment and all the labs and studies that had been done to meet the Local Coverage Determination (LCD) for hyperbaric oxygen therapy.

Most of the time, in the HOPD, the wound/hyperbaric department has no idea that an audit is underway. I talked about this in the series of interview that I did with Kathleen Shaum on the Top Ten Problems/Errors That Can Cause Money to be Lost in an Audit. Kathleen explains what everyone (including me) should have done to make sure they knew who was “on the team” when it comes to compliance. That series, which is FREE, is packed with important information.

I have heard this scenario repeated many times since it happened to me. The HOPD doctor says, “Nope, there are no problems here with Medicare audits,” but it’s just because they haven’t been told what’s going on. The story is different for office-based wound and hyperbaric centers. In the office-based setting, the physician whose payment is on the line is the one who gets the notification. In the office-based setting, the physician is the one who may have to back money if the audit goes badly. In the HOPD, the audits (at least right now) are targeting the hospital facility payment. There’s no reason Medicare can’t go after the physician’s payment for the hospital services denied by Medicare after an audit, they just haven’t done it yet.

I do not know any HOPD or office-based practice that is not being audited by Medicare for “skin substitutes” and/or HBOT charges. If your HOPD or office-based wound center practice has been spared a Medicare audit, please contact me and I will make sure that people know it’s not 100%. However, if you are in an HOPD and do not know exactly who will get the notification of an audit (and I mean, you should know their name and title) and you haven’t directly communicated with that person or department – then don’t tell me you are fine until you do.

I am not trying to fearmonger. I am trying to make sure that people know what they need to do to get ready. You can prepare for this so that your practice and/or hospital will not lose money.

–Caroline

Related posts are too numerous to list…(use the “search” feature for “audits”)

The opinions, comments, and content expressed or implied in my statements are solely my own and do not necessarily reflect the position or views of Intellicure or any of the boards on which I serve.

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