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Alphabet Soup for Waste and Fraud Inspectors

By:  ChiroCode
Published:  August 10th, 2015

The following are some of the acronyms you would need to know when communicating with auditors:

National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.

Medically Unlikely Edits (MUE): Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.

Office of the Inspector General (OIG): Don’t hire personnel on the OIG’s “No-Fly” List, a database of reputedly bad actors that have been in trouble before. Check new employees by name and verify by SSN, then keep a printout in their personnel file so you can demonstrate due diligence if you are audited. See exclusions.oig.hhs.gov.

Comprehensive Error Rate Testing (CERT): Technically these are not audits of the providers, they are conducted to see if the Medicare contractor is processing claims correctly. The focus is on insufficient documentation, medically unnecessary services, and incorrectly coded services. If the number of erroneous claims in your office exceeds a threshold (5% to 8%), expect further audits.

Recovery Audit Contractors (RAC): RACs are employed by Medicare to look for improper payments to providers. They are unique in that they are paid on a contingency basis, so they make more money when they recover more money from providers. They reportedly earn 12.5% of funds they recover, with possible bonuses above that.

Zone Program Integrity Contractors (ZPIC): Special unit that checks for Medicare fraud. They go beyond a RAC or CERT audit.

Health Care Fraud Prevention and Enforcement Action Team (HEAT): These are teams of prosecutors from the Department of Justice, US Attorney’s Office, special agents from the Office of the Inspector General and the Federal Bureau of Investigation. The purpose is to move from investigation to prosecution quickly. If these guys show up on your doorstep, you are in big trouble.

Corporate Integrity Agreement (CIA): When an entity gets in trouble with the OIG, they may choose to form a CIA with the offending entity rather than exclude them from Medicare and Medicaid. It lasts for five years and roughly includes the seven basic components of the OIG’s Compliance Plan.

Does this collection of letters frighten you a little bit? Don’t worry, ChiroCode has a team of certified auditors and compliance specialists who can help you be prepared for any trouble that heads your way.

Email DrG@ChiroCode.com to find out how we can help.

By Evan Gwilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA


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