RESPONSES- RAC audits/Fraud/pre authorization
Randy McFarland
Description
Collection
Title:
RESPONSES- RAC audits/Fraud/pre authorization
Creator:
Randy McFarland
Date:
6/21/2013
Text:
ORIGINAL POST Comments on three issues
RAC audits-
Is the claw back of Medicare funds an attempt to get at those who are
fraudently billing or is it to get funds back from those without the time or
resources to put up a fight? It IS a conflict of interest when the auditors
are paid a commission when they can arbitrarily take money back for services
provided in good faith. What is the auditors' motivation to be impartial?
What happens to them if their decision is overturned by an ALJ? What
recourse is there when someone is unfairly targeted?
Fraud-
Let's hear ideas on how Medicare could more efficiently focus in on
fraudulent billers instead of making things more difficult for everyone who
chooses to care for Medicare patients. Intentional fraud should be
prosecuted! One idea would be to have Medicare make public the name and
addresses of places that submit O&P invoices to Medicare. The legitimate
practitioners generally know about each other, but I wonder who else is
invoicing O&P procedure codes in our area that we've never heard of?
Pre-authorization-
This fiasco makes me wonder if the Medicare O&P services vetting process
should take place BEFORE services are provided rather than after the fact.
Randy McFarland,CPO
RESPONSES- separated by a blank line
I'm not on the clinical side of O&P.. I'm an engineer who has worked on
several O&P related products.. (some of which are in your supplier catalogs
now.)It seems to me that there are a couple of things going on which may
take another solution. What happens if you just put up a sign in your
office, and send a letter to all of your medicare patients that you will no
longer accept Medicare assignment. Period. You will be happy to provide the
patient with details needed to file their own claim.. but you can't afford
to do it any more. Send them details of one of the medical credit services,
to pay for your services.. and let the customer haggle it out between SSA
and their congress critter. It's pretty clear that this is a
stall/delay/deny/stall method of hoping you will fall between the cracks and
they win. It's also fairly clear that, with the limited reimbersement you
are receiving that, adding the additional administrative burden will soon
push you into an untennable position. I had a friend a long time ago, who
was audited by the IRS 7 years in a row. And at each audit, he came out
clean.. He went to federal court and got an injunction against the IRS, on
the basis of harrasment, that barred them from auditing him again, until
they showed the judge reasonable proof of fraud. To my knowledge, he was
never audited again. If you succeed in getting the denials overturned, try
going to federal court to get them to stop their harassment. Good luck.
I agree that Medicare should have pre-auths. Of course an authorization has
never stopped Humana or any other HMO from refusing to pay for one reason or
another. It's that one sentence This authorization is NOT a guarantee of
payment, let's all bear that in mind. As long as we all understand nothing
is written in stone until the check has cleared the bank it might just make
life easier on all of us. At least we'll have our refusal BEFORE we order
all the components of the prosthesis and take the hit to our pocketbooks.
Well said! I hope you do not mind that I sent it on to my Senator. I have
been having a dialog with his office concerning this situation.
RAC audits-
Is the claw back of Medicare funds an attempt to get at those who are
fraudently billing or is it to get funds back from those without the time or
resources to put up a fight? It IS a conflict of interest when the auditors
are paid a commission when they can arbitrarily take money back for services
provided in good faith. What is the auditors' motivation to be impartial?
What happens to them if their decision is overturned by an ALJ? What
recourse is there when someone is unfairly targeted?
Fraud-
Let's hear ideas on how Medicare could more efficiently focus in on
fraudulent billers instead of making things more difficult for everyone who
chooses to care for Medicare patients. Intentional fraud should be
prosecuted! One idea would be to have Medicare make public the name and
addresses of places that submit O&P invoices to Medicare. The legitimate
practitioners generally know about each other, but I wonder who else is
invoicing O&P procedure codes in our area that we've never heard of?
Pre-authorization-
This fiasco makes me wonder if the Medicare O&P services vetting process
should take place BEFORE services are provided rather than after the fact.
Randy McFarland,CPO
RESPONSES- separated by a blank line
I'm not on the clinical side of O&P.. I'm an engineer who has worked on
several O&P related products.. (some of which are in your supplier catalogs
now.)It seems to me that there are a couple of things going on which may
take another solution. What happens if you just put up a sign in your
office, and send a letter to all of your medicare patients that you will no
longer accept Medicare assignment. Period. You will be happy to provide the
patient with details needed to file their own claim.. but you can't afford
to do it any more. Send them details of one of the medical credit services,
to pay for your services.. and let the customer haggle it out between SSA
and their congress critter. It's pretty clear that this is a
stall/delay/deny/stall method of hoping you will fall between the cracks and
they win. It's also fairly clear that, with the limited reimbersement you
are receiving that, adding the additional administrative burden will soon
push you into an untennable position. I had a friend a long time ago, who
was audited by the IRS 7 years in a row. And at each audit, he came out
clean.. He went to federal court and got an injunction against the IRS, on
the basis of harrasment, that barred them from auditing him again, until
they showed the judge reasonable proof of fraud. To my knowledge, he was
never audited again. If you succeed in getting the denials overturned, try
going to federal court to get them to stop their harassment. Good luck.
I agree that Medicare should have pre-auths. Of course an authorization has
never stopped Humana or any other HMO from refusing to pay for one reason or
another. It's that one sentence This authorization is NOT a guarantee of
payment, let's all bear that in mind. As long as we all understand nothing
is written in stone until the check has cleared the bank it might just make
life easier on all of us. At least we'll have our refusal BEFORE we order
all the components of the prosthesis and take the hit to our pocketbooks.
Well said! I hope you do not mind that I sent it on to my Senator. I have
been having a dialog with his office concerning this situation.
Citation
Randy McFarland, “RESPONSES- RAC audits/Fraud/pre authorization,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235291.
