Hi Dr. Fife –
I just finished reading your blog on whether audit activity will decline now that overall expenses have come down. It’s an interesting question and, on the surface, a reasonable assumption. In practice, though, the financial return is simply too strong, and the percentage of providers who still do not appeal remains extraordinarily high. For that reason, I don’t anticipate any meaningful slowdown. In fact, I have just begun to work with a client on a 2026 audit. It will be interesting to see if the “themes” are the same in 2026.
My expectation is that contractors will continue mining 2024 and 2025 charts for vulnerabilities and then shift their focus to 2026 claims with far greater scrutiny on how wastage is reported and documented since it is no longer reimbursable. The longstanding practice of folding excess graft onto itself will not withstand review, and if depth, undermining, tunneling, or other clinically relevant factors are not explicitly documented as the basis for excess product, repayment is almost guaranteed.
I am currently gathering data on denial rationales, effective rebuttal themes, and observable contractor behavior patterns in order to identify which arguments consistently influence outcomes and to establish a more data driven framework for forecasting auditor trajectories. I will keep you posted on my findings.
Michael J. Crouch, CPC, CPMA, CHT-ADMIN
michaelcrouch@cplushealthcareconsulting.com
www.cplushealthcareconsulting.com
Dr. Fife,
Regarding skin sub audits, I am a wound care practitioner who has assisted many of my colleagues at the Administrative Law Judge (ALJ) audit level. My personal experience is that practitioners are unlikely to win their ALJ appeal if they cannot produce published evidence on the clinical benefit of the product they used.
As has been pointed out on your blog, the pathway to market determines what claims that a manufacturer can make. When a clinician states in the chart that they utilized a specific human tissue product because it would (for example) “help heal” the wound – the auditors pounce – often with success. You have posted a blog by Michael Crouch about auditors denying claims on the basis of amniotic tissues being called “experimental.” In a subsequent post, Mr. Crouch stated that the ALJ reversed the contractor denial for this reason, but my personal experience is different.
ALJ decisions vary widely. Manufacturers need to publish data on the real-world wound outcomes with their product(s). Otherwise, clinicians (particularly those who used high-priced amniotics) are going to be repaying a lot of money. The sad fact is that, now that skin sub manufacturers’ revenue has plummeted, support for clinical research (with a few notable exceptions) has plummeted. This bodes ill in the audit world.
[Name withheld on request]
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.
