Attorney Knicole Emanuel recently blogged about Medicare audits. It’s a good news/bad news story. The good news is that a physician who was determined by an auditor to have been “over paid” by $5 million ended up owing NOTHING. The bad news is that the cost of taking this case all the way to an administrative law judge was not inconsequential. Ms. Emanual’s point is that if auditors had to pay the legal fees of physicians who prevailed in court (meaning, if the auditor was WRONG), the auditors would be more likely to focus on the real fraudsters. I agree that holding auditors accountable for legal costs could be wonderful – and will happen about the time I sprout wings.
The sad fact is that there is lot of Medicare and Medicaid fraud in every sector of healthcare. And the only tool that Medicare has to protect the fee for service (FFS) system is to audit mercilessly. As a result, I don’t know anyone in wound care who has NOT been audited by at least one of the “alphabet soup” Medicare audit programs. And truthfully, the audits can be designed to ensure failure. How? Consider that the local coverage determination (LCD) in my Medicare region (Novitas) required 24 specific “things” to be documented when a skin sub/CTP was used.
I have analyzed the proposed LCD(s) for CTPs/skin subs, and the new policies will require at a minimum, more than 40 specific elements of documentation. (It’s a lot more than that depending on the specific scenario). I spend a lot of my time these days trying to ensure that clinicians have a documentation system that helps them be compliant with these demands– but the perfect documentation tool is not enough. Clinicians must be obsessive about their documentation. Otherwise, it’s just like the treadmill gathering dust at my house. Having tool is not the same as using it. What is even more frustrating is that physicians have failed audits when the required documentation was clearly in the chart – but the auditor ignored it, was too clinically ignorant to understand it, or too lazy to look for it. As a result, physicians with audit experience end up printing out the entire chart and then creating an “index” of exactly where each requirement is to be found in the chart. What a huge time suck for physicians!
The point is that even practitioners who are so virtuous that their shiny halo is visible can still end up paying money back to Medicare – or spending a lot of money on lawyers – when the care they provided was clinically appropriate. It is the huge price that everyone pays because of overuse and improper use by some. The audit situation is not going to get better any time soon, so clinicians will just have to spend more time ensuring that their documentation is as close to perfect as possible.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
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.
