At this point, thanks to a three-year demonstration project and a plethora of available information available for providers, the healthcare industry generally knows what providers are up against in terms of RAC audits. Not that they'll be easy to handle, but there's a lot of information out there for providers to help them manage the process.
Unfortunately, comparatively few providers seem to know what to expect with Medicaid Integrity Program audits—which have already begun in many areas across the nation—and in many cases, information that could help them is lacking.
CMS plans to update its Web site with much more information, according to CMS representatives who spoke on the last Open Door Forum call on the subject, and providers are waiting with baited breath. Providers may also be able to find some helpful information on their individual state's Medicaid Inspector General Web site. But in comparison to RACs, information on Medicaid Integrity Program audits is generally difficult to come by.
In addition, there also seems to be a lack of information available from providers who have already been audited by Medicaid Integrity Contractors (MIC). Perhaps with one more auditor to deal with, providers are simply too busy to share. But many providers are looking to their peers to reveal the lessons they learned and the strategies they developed to deal with the Medicaid auditing activities even a little more easily.
One provider recently noted that a MIC had already requested hundreds of records from her hospital—there is no record request limit unlike the one in place for RACs. They can ask for as many as they want, as often as they want, she said. "And I think we had 15 days to respond. It's ridiculous." (MICs must adhere to state laws in this regard, so the time providers have to turn in records will differ depending on the state in which they are located.)
What are MICs looking for? Again, this differs from state to state. One provider indicated evaluation and management (E/M) codes were audited in her hospital's clinic areas. "When MICs found a preponderance of higher codes that didn't exactly meet the bell curve, they asked for the documentation for the higher levels. And we had to produce it all."
RACs may also audit E/M codes, but they have chosen to begin with more straightforward, automatic reviews. In addition, at least for Medicare Part B physician claims, CMS has indicated it will work closely with the AMA and the physician community prior to any E/M level auditing and will provide notice to the physician community before the RACs begin E/M audits.
Providers need to figure out how to meet MIC record requests and appeal deadlines. And surely they'd appreciate learning about MIC target areas. But again, information is difficult to come by, and much of it will differ from state to state, making the process that much more complex.
But as one provider said: "MICs are aggressive here. Very, very aggressive. And we're really being pushed."
So providers need to learn all they can, however they can, and as soon as they can about Medicaid Integrity Program audits to help them prepare.
Editor's note: For more on Medicaid audit activities, consider attending the upcoming to the upcoming HCPro audio conference, "Medicaid Integrity Contractor Audits: Know What to Expect and How to Prepare," to be held October 15. Speakers include James G. Sheehan, the New York State Medicaid Inspector General, and Sarah Kay Wheeler, partner at King & Spaulding in Atlanta.