Here’s another fantastic post from attorney Knicole Emanuel about the serious overreach problems inside the alphabet soup of Medicare audits. This is an issue that will get even more problematic due to the delay of the “skin substitute” LCD(s). Some auditors are behaving as if the LCD(s) are in effect. Audits are the only tool that the Centers for Medicare and Medicaid Services (CMS) has to handle waste, fraud and abuse in the Medicare Fee For Service (MFFS) program. The companies contracted by CMS to perform these audits get a percentage of the money “recuperated,” so they have a monetary incentive to ensure that doctors fail. It can take years to resolve some audits as you work through the various levels of appeal, and some of the audit programs carry the risk of paybacks going back several years – based on what they have determined your “failure rate” to be.
Ms. Emanuel describes the most common ways in which auditors overreach their authority as follows (taken directly from her blog):
Misapplication of Medical Necessity Criteria:
- Auditors often retroactively decide that services were not medically necessary—because obviously, they have a medical degree from the University of Hindsight. In fact, rarely are these audits peer to peer. Nurses determine medical necessity for doctors.
Flawed Extrapolation Methodology:
- Many auditors review a small sample of claims and extrapolate their findings across thousands of claims, a bit like deciding your entire meal is bad based on one burnt French fry.
Failure to Consider Provider Documentation:
- Providers meticulously document services rendered, yet auditors often treat this documentation like an Ikea manual—confusing, unnecessary, and best ignored.
Wound care practitioners have experienced all of these, and I have talked about some of those egregious situations before. While many people may be celebrating the delay in the implementation of the LCD(s) – we know that auditors have used the criteria in those not-enacted LCD(s) when performing audits on clinicians using “skin substitutes”. It’s a problem that the Alliance of Wound Care Stakeholders is trying to address. Many physician practices are joining the Alliance to help engage in the fight against unfair audits.
Be sure to read all of Ms. Emanuel’s article, which calls for radical reforms such as holding auditors accountable for mistakes. Until that happy day dawns, practitioners need to assume they will be audited – and that perhaps the still-not-final LCD(s) will be used as the criteria to determine medical necessity for diabetic foot ulcers and Venous leg ulcers. Ms. Emanuel closes with this:
“While preventing fraud is essential, the current model disproportionately punishes honest providers, forcing them to fight lengthy and costly appeals just to keep their doors open… Until meaningful reforms are enacted, providers must remain vigilant, meticulously document their services, and aggressively pursue appeals to challenge erroneous audit findings. The fight against unfair audits continues, and providers must be prepared to defend their practices against overzealous scrutiny…”
–Caroline
See all blog resources on audits at this page.
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.
