What Radiology Facilities Need to Know about Medicare Audits

MINNEAPOLIS - You’ve heard the acronyms: CERT, MAC, ZPIC, RAC. The terminology of Medicare auditing may sound like gibberish, but as healthcare providers nationwide face increasing threats of audits, it’s a language all radiology practices should learn to speak.

“It’s possible to win these cases,” said Jessica Gustafson,  an attorney and partner with The Health Law Partners PC who devotes a majority of her practice to pursuing Medicare audit appeals. “Just because a CMS contractor … says a claim is medically unnecessary or improperly billed, that doesn’t mean they’re right. And often times they aren’t.”

If a radiology facility faces a Medicare audit and is considering appealing, it’s first important to understand the different kind of auditors. 

Comprehensive Error Rate Testing (CERT) audits measure improper payments in the Medicare fee-for-service program. If a CERT contractor identifies an overpayment, providers can appeal the finding, said Gustafson, who spoke this week at the AHRA 2013 annual meeting.

Gustafson said it’s especially critical to appeal questionable CERT claim findings, because other auditors use the results of the CERT audits to identify vulnerabilities within the Medicare program.

“If the CERT auditor finds there’s a very high error rate in radiation oncology, for example, then other auditors may focus their auditing efforts on that particular type of service,” she said.

Medicare Administrative Contractor (MAC) audits are those that target problem areas identified by CERT contractors. MACs actually have the ability to withhold funding from a practice until the facility submits the documentation required by the audit.

Zone Program Integrity Contractor (ZPIC) audits focus on the investigation of fraud and abuse, and Recovery Audit Contractor (RAC) audits deal with improper payments, including incorrectly coded services or duplicate services.

Auditing activity across the board is on the rise, due to factors such as the use of electronic health records and the upcoming implementation of ICD-10, a new, more detailed medical coding system.

Adrienne Dresevic, an attorney and founding partner of The Health Law Partners PC who focuses on Stark law and fraud and abuse, said she once had a client who had to go through three levels of the appeals process because the signatures failed to show up on the printed-out electronic records.

Dresevic suggested radiology facilities prepare for increased claims scrutiny by naming a point person responsible for communicating with CMS contractors, responding to records requests and monitoring areas that may be subject to review. Areas that are at a high-risk for a RAC audit are listed on the CMS website.