Recorded Webinar | Knicole C. Emanuel | Nov 12 ,2021 | 1:0:pm EST | 60 Minutes
Description
To address health care fraud, waste, and abuse (FWA), Congress and CMS developed a variety of approaches over the past several years to audit Medicare and Medicaid claims. For all the different approaches, the government created rules and different acronyms. For example, a ZPIC audit varies from a CERT audit, which differs from a RAC audit, etc. The rules regulating the audit differ vastly and impact the provider’s audit results greatly. It can be as varied as hockey and football; both have the same purpose of scoring points, but the equipment, method of scoring, and ways to defend against an opponent scoring are as polar opposite as oil and water. It can be confusing and overwhelming to figure out which entity has which rule and which entity has exceeded its scope in an audit.
It can seem that we are caught swimming in a bowl of alphabet soup. We have RACs, ZPICs, MICs, CERTs, and PERMs!!
What are these acronyms??
This webinar will shed some light on the different types of agencies auditing your Medicare and Medicaid claims and what restrictions are imposed on such agencies, as well as provide you with useful tips while undergoing an audit and defending the results.
First, what do the acronyms stand for?
Second, what are the allowable scope, players, and look-back periods for each type of audit? I have comprised the following chart for a quick “cheat sheet” when it comes to the various types of audits. When an auditor knocks on your door, ask them, “What type of audit is this?” This can be invaluable information when it comes to defending the alleged overpayment.
| Name | Scope | Auditor | Look-back period |
| Medicare RACs
Focus: Medicare overpayments and underpayments | Medicare RACs are nationwide. The companies bid for federal contracts. They use post-payment reviews to seek over and underpayments and are paid on a contingency basis. | Region A: Performant Recovery
Region B: CGI Federal, Inc. Region C: Connolly, Inc. Region D: HealthDataInsights, Inc. | Three years after the date the claim was filed. |
| Medicaid RACs
Focus: |
Medicaid RACs operate nationwide on a state-by-state basis. States choose the companies to perform RAC functions, determine the areas to target without informing the public, and pay on a contingency fee basis. | Each state contracts with a private company that operates as a Medicaid RAC.
In NC, we use PCG and HMS. | Three years after the date the claim was filed unless the Medicaid RAC has approval from the state. |
| MICs
Focus: | MICs review all Medicaid providers to identify high-risk areas, overpayments, and areas for improvement. | CMS divided the U.S. into five MIC jurisdictions.
New York (CMS Regions I & II) – Thomson Reuters (R) and IPRO (A) • Atlanta (CMS Regions III & IV) – Thomson Reuters (R) and Health Integrity (A) • Chicago (CMS Regions V & VII) – AdvanceMed (R) and Health Integrity (A) • Dallas (CMS Regions VI & VIII) – AdvanceMed (R) and HMS (A) • San Francisco (CMS Regions IX & X) – AdvanceMed (R) and HMS (A) | MICs may review a claim as far back as permitted under the laws of the respective states (generally a five-year look-back period). |
| ZPICs
Focus: Medicare fraud, waste, and abuse | ZPICs investigate potential Medicare FWA and refer these cases to other entities.
Not random. | CMS, which has divided the U.S. into seven ZPICs jurisdictions.
Only investigate potential fraud. ZPICs are not paid on a contingency fee basis. | ZPICs have no specified look-back period. |
| MFCUs
Focus: Medicaid fraud, waste, and abuse | MFCUs investigate and prosecute (or refer for prosecution) criminal and civil Medicaid fraud cases. | Each state, except North Dakota, has an MFCU. | MFCUs have no stated look-back period. |
| CERT
Focus: Medicare improper payment rate | CERT companies indicate the rate of improper payments in the Medicare program in an annual report. | CMS runs the CERT program using two private contractors (which I am yet to track down, but I will). | The look-back period is the current fiscal year (October 1 to September 30). |
| PERM
Focus: Medicaid improper payment rate | PERM companies research improper payments in Medicaid and the Children’s Health Insurance Program. They extrapolate a national error rate. | CMS runs the PERM program using two private contractors (which I am yet to track down, but I will). | The look-back period is the current fiscal year (the complete measurement cycle is 22 to 28 months). |
As you can see, the soup is flooded with letters of the alphabet. But which letters are attached to which audit company determines which rules are followed.
It is imperative to know, when audited, exactly which acronym those auditors are. This webinar will explain the variances among the multiple auditors.
Learning Objectives:-
Who Should Attend:-
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