by Robert Liles, JD, MBA, MS
April 20th, 2018
At last estimate, the Medicare Administrative Contractors (MACs) processed an estimated 1.2 billion claims on behalf of America's seniors. As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud
I. Providers and Suppliers Currently Subject to the PSAVE Pilot Program:
Last November, Noridian Healthcare Solutions LLC (Noridian), the MAC for Jurisdiction F, and CMS launched a pilot Medicare claims self-auditing program. Jurisdiction F is comprised of Alaska, Arizona, Idaho, Montana, North Dakota, Oregon, South Dakota, Utah, Washington, and Wyoming. When announced, the program was touted as a way to provide educational benefits to Medicare providers, while also granting "immunity" from
II. Why Was Your Practice Invited to Participate in the PSAVE Pilot Program?
While Noridian claims that the PSAVE program is open to almost any Medicare Part B healthcare provider, invitations to participate
III. How Does the PSAVE Pilot Program Work?
At the outset, it is important to keep in mind that if your practice was invited to participate, your billing practices have been found to be aberrant by a CERT contractor. As an outlier, your practice's Medicare claims for reimbursement have been targeted for audit.
Potential participants were sent (or will be sent, as the program expands) a notification letter by Noridian which included a sample listing of claims that the MAC has identified for inclusion in your self-audit. In addition, Noridian's letter also specified the elements that it expected each provider to review in connection with the claims. Noridian's notification letter also included an "Appeals Waiver" form that it required participating providers to sign prior to being admitted into the pilot program.
IV. Benefits of Participation in the PSAVE Pilot Program:
Perhaps the greatest benefit of participation is the fact that you are in charge and you are directly involved in the claims audit process. As the audit progresses, you will be aware of any problems that may arise with your claims. In simplified terms, self-audits provide you with a significant degree of control over the process. Nevertheless, just because you may exercise a significant degree of control over the audit process does not mean that you will be able to control the outcome of the audit. As with other self-audit / self-reporting programs administered by CMS and the Office of Inspector General (OIG), a provider's voluntary participation in the PSAVE pilot program allows a provider to present its view of the claims in the best possible light while positioning itself as a "Good Corporate Citizen."
V. PSAVE Pilot Program Risk Issues:
While proponents of the PSAVE pilot program are quick to point out the educational value of participating in the program, a provider should exercise care before deciding to sign on to the program. For example, the Appeals Waiver signed can leave a provider vulnerable at the conclusion of the program, as there is no mechanism
Additionally, PSAVE representations extolling the benefits of immunity from subsequent MAC and RAC audits (limited to the specific claims or extrapolated claims set covered by the PSAVE audit) is somewhat misleading. The promised immunity from audit does not apply to Unified Program Integrity Contractor (UPIC) / Zone Program Integrity
VI. Risks Encountered When Opting-Out of the PSAVE Pilot Program:
Should you decide to decline Noridian's invitation to participate, you need to keep in mind that the likelihood of being subjected to a compulsory audit by Noridian, the UPIC / ZPIC or even OIG is quite high. Your practice's billing practices have already been identified as problematic. If targeted in a future
How should you proceed? If your practice is invited to participate in the PSAVE pilot program, you need to carefully consider the risks of choosing to participate. The PSAVE pilot program is merely one of the most recent efforts by CMS to educate providers on their medical necessity, documentation, coding and billing obligations. Although the PSAVE pilot program may advance the agency's overall goal of reducing Medicare waste, fraud and abuse, there are other more effective, less invasive ways for your practice to integrate and encourage a culture of compliance in your organization.
Adherence to the requirements set out in a well-designed Compliance Program is perhaps a Part B provider's best approach to expedite and optimize the proper payment of claims, minimize billing mistakes, and reduce the chances that an audit will be deemed necessary by CMS or one of its program integrity contractors.