Things You Need To Know To Prevail In A Medicare Audit

With heightened scrutiny of health care fraud involving the emergency medical services (EMS) industry, ambulance providers are more likely than ever to face Medicare audits. Not to be taken lightly, these audits can result in significant penalties—including being excluded from federal health care programs—and even criminal charges.

Medicare audits can be overwhelming, but it’s crucial to understand the requirements in order to prepare for a successful outcome. Taking proactive steps now can help ensure a painless audit process.

Here are five essential things to know:


Know the common
audit triggers

Most audits are driven by a statistical analysis done by your Medicare Administrative Contractor (MAC).

These audits take two forms: prepayment review and post-payment review. In both cases, the MAC investigates three key elements of each claim:

  • Is it Advanced Life Support or Basic Life Support?
  • Is it an emergency or non-emergency response?
  • Is the ambulance transport medically necessary?

Providers have up to 30 days to submit the required documentation, and the MAC has up to 60 days to send its response. If the contractor does not receive information in a timely manner, it’s an automatic denial, and unanswered requests can increase the scope of the audit.


Know what to expect in
both prepayment and
post-payment reviews

In a prepayment review, the ambulance provider will receive one letter requesting documentation for every flagged claim, usually for the same service, to be reviewed individually. These reviews are typically triggered when the Medicare contractor determines that a provider ranks higher in ALS or emergency procedures as compared to their geographical peers. This is often apples to oranges, as the country fire/EMS service will naturally have a different patient profile than a private ambulance service specializing in dialysis or nursing home transports.

A post-payment review examines the provider’s entire universe, using a set of randomly selected trips for statistical analysis. (RAT-STATS, the statistical tool used for these reviews, is available as a free download for providers to perform in-house compliance audits). The provider then is required to submit all of the medical records for those trips to the MAC.

If the MAC’s analysis determines a high rate of error, that rate is extrapolated to all the claims across that provider’s universe. For example, if they determine a 40 percent error rate on 90 randomly selected trips over 24 months, then Medicare has the justification to apply that error percentage to every claim submitted in that same two-year period.

The provider will then receive a letter that specifies an amount that must be repaid. If Medicare doesn’t receive payment within the allotted time, the money – plus interest – will be withheld from future checks.


Boost compliance by
training medics and
staff to keep
meticulous records

It’s important to have an active compliance plan in place, as well as a compliance manager to conduct internal quality assurance audits. Part of that compliance plan should include training for both medics and billing staff to ensure that they are up to date on the latest regulations. This demonstrates due diligence if you are audited.

Train medics on what information is needed in a patient care report to support all procedures and medications provided so that the billing department can apply the correct codes. That training should not be geared toward getting every claim paid. Details matter, but medics should never add or omit information to justify basis for payment.

Also be sure to provide the required signatures, which will include both billing authorization and medic signatures. It is also important to ensure that the appropriate verbiage is available on the PCR as well. Make sure that medics’ signatures are legible and their credentials provided on each PCR. (PCR software helps with this requirement by providing e-signatures when medics log in.) Non-emergency ambulance transports also require a valid physician certification statement with legible signatures from an appropriate medical clinician (MD, RN, etc.).


Always appeal the
MAC’s determinations

Stand by your coding and don’t be afraid to appeal. The Medicare appeals system has four sequential levels. The first two are reviewed by Medicare contractors and handled by written correspondence. The third and fourth are reviewed by independent contractors or an administrative law judge, and providers can request a call or visit to discuss the issue. Further appeals go to federal court.


Enlist a third party
for help

A billing and compliance specialist can help navigate the process, handling billing, audits and appeals on your behalf. A company like EMS|MC can also offer an external review of your billing practices and a mock audit to identify aberrancies and assess risk. And if you handle your own billing but find yourself in the middle of an audit, a third party can step in to assist with the appeals process—letting your staff focus on what matters: helping patients.

EMS|MC’s compliance program is designed to safeguard you from unintentional billing practices that violate Federal law.

To learn more, download the eBook: Navigating EMS Compliance: The Strategic Guide to Establishing an Effective Compliance Plan.

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