What Physicians Need to Know About Fraud and Abuse Prevention Updates

April 3, 2014

A new report released by the OIG identifies areas of improvement for fraud and abuse prevention and Medicare billing integrity.

On March 18, the Department of Health and Human Services, Office of the Inspector General's (OIG) "Compendium of Priority Recommendations" was released. The report addressed the top 25 unimplemented recommendations, which would serve to protect the integrity of HHS programs. For physicians, two areas are of particular note: fraud and abuse prevention and recovery audit contractors (RACs).

Overall, the recommendations were to improve controls to undercover fraud and preserve the integrity of Medicare billings. Section 4 of the report is particularly useful as it identified recommendations to "[e]nsure that the Audit Tracking and Reporting System is updated to accurately reflect the status of audit report recommendations, ensure that collections information is consistently recorded in the Audit Tracking and Reporting System, and collect sustained amounts related to OIG recommendations made after our audit period to the extent allowed under law." These recommendations were based on two previously issued reports from the OIG.

Section 23 relates to the reliance of CMS on contractors to administer various programs and recover funds for Medicare Part A and Medicare Part B. "CMS should provide guidance to claims processors about handling [for program integrity purposes] Medicare Summary Notices (MSNs) that are returned as undeliverable." CMS may consider seeking a legislative change to increase the time between "MAC contract competitions to give CMS more flexibility in awarding new contracts." Hence, more incentive to have accurate billing practices in place.

Armed with this knowledge of more emphasis being placed on fraud and abuse prevention, as well as maximizing recovery of overpayments, physicians should look at this aspect of their revenue cycle closely.