Update All of Your Addresses with Medicare Immediately!

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Have You Checked Your Addresses on File with CMS/Medicare Recently?

Do you remember the last time you checked all four of the addresses you should have on file for any individual or any group/company Medicare number you may have?  The consequences of not updating these addresses can be severe.  In addition to your mailing (or correspondence address), and your billing address, you also should have a physical address that is complete, accurate and timely.  The telephone number for that physical address should also be in the system.  You must ensure that not only is the street address accurate, but also that any suite, office or apartment number on it is accurate.  Check the zip code, too, just to be certain you did not transpose digits when you entered it.

Auditors, surveyors, inspectors and investigators are often sent out by Medicare and its contractors, including the Medicare Administrative Contractors (or “MACs”) and the Zone Program Integrity Contractors (or “ZPICs”), to the physical address on file.  This is done as a fraud prevention tool to make sure that medical practices, durable medical equipment companies (DMEs), home health agencies (HHAs), and other businesses that receive payments from Medicare are legitimate and are actually operating.

Termination of Medicare Billing Privileges Often Results From Incorrect Addresses.

Site inspections and audits are also conducted by sending auditors on short notice or no notice to the physical address on file.  If your physical address is incomplete (e.g., no suite number) or wrong (e.g., incorrect street address) or is not up to date (e.g., you moved and forgot to update it), the consequences could be severe.  What we have seen most often recently is an action that terminates the Medicare billing privileges.  The provider then is not allowed to reapply for a period of two (2) years from the date of termination.

Update All of Your Addresses with Medicare Immediately.

I urge you to personally and immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information to check it.  If your address is incorrect or incomplete, immediately submit a correction or have your administrator practice manager do this.

If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately have this corrected, as well.  Everything should be consistent, and all of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information, as well.

What to Do if You Receive a Notice of Termination of Your Medicare Provider Number.

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare billing privileges of many different Medicare providers including physicians, medical groups, home health agencies (HHAs), pharmacies, and durable medical equipment (DME) providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old, incorrect addresses.

Often the termination is retroactive to an earlier date when the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

1. You are prohibited from reapplying to Medicare for at least two (2) years.

2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).

3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).

4. You may no longer contract with Medicare or anyone who does.

5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.

6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.

7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

1. Don’t bother to write letters or start e-mailing anyone, including CMS or the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).

2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS) or the MAC.

3. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).

4. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.

5. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)

What we recommend is:

1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).

2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.

3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.

4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination.  Train your management and staff on these.

The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

1. Documents showing how the error occurred or past efforts to comply.

2. Surety bond guarantees and documents (where required).

3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).

4. Current licenses and permits.

5. Certificates of good standing and latest annual reports for any corporation or limited liability company.

6. Print-outs from PECOS/NPPES Registry discussed above.

7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).

8. Certificates of compliance training for you and your staff, if available.

9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.

10. An authorization form for your consultant or attorney to represent you in the matter.

All copies should be clear, legible, complete, straight, no corners cut off and no handwriting on them, to the greatest extent possible.

Organize, Label and Index Professionally.

Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.

Don’t Wait Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions.  They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.  Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

Disclaimer:  Please note this article is for general education and information purposes only and does not constitute legal advice or solicitation for clients.  Our opinions stated herein are just that, our opinion.

Medicare Fraud Initiative Leads to Arrests of Over 100 Health Professionals

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A recent Medicare fraud operation conducted between several federal agencies has resulted in the arrest of over 100 doctors, nurses and other medical professionals. They have been charged with various crimes relating to Medicare fraud. The arrests were made on May 2, 2012 in seven cities nationwide, but more than half took place in South Florida.

This  multi-agency attack on medical professionals and health care providers was a joint effort between law enforcement agents from the Federal Bureau of Investigation (FBI), Department of Health and Human Services-Office of Inspector General (HHS-OIG), Medicaid Fraud Control Units (MFCU) and other state and local law enforcement agencies. In addition to arresting over 100 medical professionals, these agents also executed 20 search warrants in connection with ongoing Medicare fraud investigations.

Some of the charges against the health care professionals include conspiracy to commit health care fraud, health care fraud, violations of the anti-kickback statutes and money laundering. The charges are based on a variety of alleged Medicare fraud schemes involving medical treatments and services such as home health care, mental health services, physical and occupational therapy, durable medical equipment (DME), mental health counseling and ambulance services. These alleged Medicare fraud schemes resulted in a combined $452 million in false billings.

HHS also took other administrative action against 52 other health providers. These providers were tracked down through data analysis and are also accused of Medicare fraud. Because of the Affordable Care Act, HHS will be able to suspend payments to these providers the entire time until the investigations are completed.

Because of the severe state budget shortfalls and the federal deficit, we are seeing a tremendous increase in both Medicare and Medicaid fraud initiatives. If you are being accused of Medicare or Medicaid fraud, it is extremely important to retain an experienced health attorney immediately.

Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now Before it is Too Late

The lawyers of The Health Law Firm routinely represent physicians and other healthcare professionals in Medicare and Medicaid investigations, audits and recovery actions. They also represent physicians and health professionals in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.

Sources Include:

Weaver, Jay. “Feds Arrest More Than 100 Medicare Fraud Suspects in South Florida, Nationwide.” Miami Herald. (May 02, 2012). From
http://www.miamiherald.com/2012/05/02/2779369/feds-arrest-about-100-medicare.html

U.S. Department of Justice, Office of Public Affairs. “Medicare Fraud Strike Force Charges 107 Individuals for Approximately $452 Million in False Billing.” U.S. Department of Justice. Press Release. (May 02, 2012). From http://www.justice.gov/opa/pr/2012/May/12-ag-568.html

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

ZPIC or Medicare Audit and Site Visit Checklist

As a physician, medical group or other healthcare provider, if you receive a notice of an audit and site visit from Medicare, the Medicare Administrative Carrier (MAC) or the Zone Program Integrity Contractor (ZPIC), things happen fast with little opportunity to prepare. Hopefully this checklist will help you to prepare for the on-site visit that will shortly follow.

Many items on this checklist may seem common sense to the reader; however, they would not be on here if I did not encounter them as problems in at least two different instances for each one.

1. Immediately check your address on the letter to ensure it is the correct and complete physical address of the site visit, including the suite number.
2. Immediately call and make telephone contact with the auditors.
3. Immediately call and advise your health care attorney and have him/her present at the audit and site visit.
4. If the site visit is set for a branch office, make sure the appropriate administrative personnel and at least one of the treaters who see Medicare patients are in that office on the day of the site visit
   
5. Conduct a self-inspection of your office immediately; call for an emergency house-keeping visit to clean if necessary.
   
6. Make sure all displayed licenses and certificates are current.
   
7. Make sure all patient health records are properly secured and your medical record handling and storage are complaint with HIPAA standards.
   
8. Have a separate room set aside for the auditors to use with chairs and a flat surface (desk or table) for them to use as their meeting room, conference room and interview room.
   
9. Make sure your office is “photogenic.”
10. Require proper photographic identification and identifying information from each member of the audit team.
    
11. Assign one main staff person as communication point with the auditors (and your attorney).
    
12. Keep a copy of every document or paper you provide to the auditors during the site visit.
    
13. Be aware of scrutiny of policies and procedures for narcotics or pain medications.
    
14. If the records needed by the auditors are in a different office of the practice, don’t kill yourself getting them during the site visit.
    
15. Don’t guess at the answers to the questions asked by the auditors.
    
16. Expect to be asked for your drug list or formulary.
    
17. Do ask questions of the auditors.
    
18. Do not voluntarily advise the auditors of suspicions of wrongdoing or ask if what you are doing is correct.
    
19. Keep good copies of and document your transmittal of documents to the auditors.
    
20. If additional time is needed, request it by telephone and confirm it in writing.

Although this checklist just scratches the surface of the audit process, I hope you find it of some help in preparing for any upcoming audit involving a site visit.

 

For more information about ZPIC, Medicare, Medicaid or other healthcare audits, please visit our website at www.TheHealthLawFirm.com.

“Cert Audits” Newest in Medicare Audit Contractor Alphabet?

One of the newest acronyms that our law firm has encountered in the Medicare Program’s audit process is the Medicare Comprehensive Error Rate Testing program audit or CERT audit.  It could be that we just haven’t had clients who had problems with this in the past, as we have seen plenty of Zone Program Integrity Contractor (ZPIC) audits, Medicare Administrative Contractor (MAC) audits and actions, Medicaid Fraud Control Unit (MFCU) audits, etc.  However, we did have a client recently who was being audited by a CERT contractor and we assisted in resolving document discrepancies.

The Centers for Medicare & Medicaid Services (CMS) created the Comprehensive Error Rate Testing (CERT) program to measure the paid claims error rate for Medicare claims submitted to Medicare administrative contractors, carriers, durable medical equipment regional carriers, and fiscal intermediaries (now Medicare Administrative Contractors or MACs) .  CMS receives in excess of two billion claims annually.  The CERT program randomly selects approximately 120,000 of these claims for review to determine whether the claims were properly paid.

Statistical samples are selected and the CERT documentation contractor (CDC) submits documentation requests to those providers who submitted affected claims.  Once the requested documentation has been received, the information is forwarded to the “CERT review contractor” (or CRC) for review.  The CRC will review the claims and supporting documentation to measure compliance with Medicare coverage, coding and billing rules.

As with many audits, it  seems like the most common problems being detected have to do with medical records errors, such as the documentation not supporting the code billed, absence of signatures on medical record entries, wrong dates of service, absence of medical record documentation, illegible records, wrong provider being billed for, etc.

We have been pleasantly surprised, however, when our personal phone calls to CDC and the CRC have been answered and actual accurate information provided, as well as letters and documents we provided being promptly acknowledged.  Like with any other audit, however, we urge those being audited to seek the advice of an experienced health law attorney who may be able to assist in heading off and avoiding a more serious investigation or a large repayment demand eventually resulting.

For more info see:  http://www.cms.gov/MLNProducts/downloads/MCRP_Booklet.pdf

or visit our website at:  www.TheHealthLawFirm.com

Have You Received a Notice of Termination of Your Medicare Provider Number?

Have you received a notice of termination of your Medicare provider number? Medicare has been revoking the Medicare provider numbers of many different Medicare providers including physicians, medical groups, home health agencies (HHAs), pharmacies, and durable medical equipment (DME) providers, based on returned mail sent to old addresses which have not been updated or based on inspection team site visits to old addresses.

Often the termination is retroactive to a much earlier date the change or move may have been determined to have occurred. Even if the mailing address is correct or was changed, the physical address of the business must have been updated, as well. It is usually an incorrect or old physical address which causes this to occur.

The effect of this termination includes:

1. You are prohibited from reapplying to Medicare for at least two (2) years.
2. You may have to pay back any monies received from the Medicare Program since the effective date of the termination (often many months prior to the notification letter).
3. Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPIC) and the state Medicare Fraud Control Unit (MFCU).
4. You may no longer contract with Medicare or anyone who does.
5. You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.
6. You may and probably will be terminated from skilled nursing facilities (SNFs) and home health agencies (HHAs) with which you have contracts.
7. You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs) where you have them.

What you should not do includes:

1. Don’t bother to write letters.
2. Don’t bother to call the Centers for Medicare & Medicaid Services (CMS).
3. Don’t bother to call the Medicare Administrative Contractor (or MAC) (previously called the “carrier” or “fiscal intermediary”).
4. Don’t bother to file a new CMS Form 855 (application) or a CMS Form 855C (change).
5. Don’t bother to start communicating with CMS or the MAC about your situation and what you need to do about it.
6. Don’t bother to complete and file the short, one-page Corrective Action Plan (CAP) form that is on the CMS or Carrier/MAC website (unless you are close to the deadline and don’t have representation; then you must.)

What we recommend is:

1. Immediately go into the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and the National Plan & Provider Enumeration System (NPPES) NPI Registry and print out a copy of the existing information. Then update or correct any incorrect information on you or your company, if you can. Print out the information as it existed before and print out the information after you have corrected it. (Note: Medicare will act shortly after the letter to you to terminate your access to this, so it may be too late).
2. Hire an experienced health attorney immediately to assist you in putting together and submitting a comprehensive Corrective Action Plan (CAP), a Request for Reconsideration (RFR) and a request for an Appeal Hearing.
3. Note that there is a thirty (30) day deadline for submitting the CAP and a sixty (60) day deadline for requesting an appeal hearing. Do not miss these.
4. Implement formal, written internal policies and procedures to prevent a recurrence of the type of error, oversight or event that caused the termination. Train your management and staff on these.

The CAP should address every element of the applicable conditions of participation (COP) contained in the Code of Federal Regulations (CFR). It should include and be supported by all relevant documents, including but not limited to:

1. Documents showing how the error occurred or past efforts to comply.
2. Surety bond guarantees and documents (where required).
3. Insurance coverage documents showing current coverage (general liability, professional liability, vehicle/auto liability).
4. Current licenses and permits.
5. Certificates of good standing and latest annual reports for any corporation or limited liability company.
6. Print-outs from PECOS/NPPES Registry discussed above.
7. Accident reports, insurance claims, police reports, fire reports or other documentation showing why a relocation was required (if this was an issue).
8. Certificates of compliance training for you and your staff, if available.
9. Copies of policies and procedures that you have adopted to keep there from being a recurrence of the situation that led to the termination.
10. An authorization form for your consultant or attorney to represent you in the matter.

All copies should be clear, legible, complete, straight, no corners cut off an no handwriting on them, to the greatest extent possible.

Everything should be professionally assembled, typed, indexed and labeled. It should include a table of contents or an index. Number every page. It should be submitted to the MAC (or the agency/address given in the termination letter) by two (2) reliable means that document both sending and receipt. Keep copies of everything, including postal receipts, airbills, Federal Express labels, courier receipts, etc. It must be received at the address given in the termination letter you received (usually MAC) by the deadline given above. Keep copies of online tracking reports and return receipts.

In most instances, should you show a legitimate reason for the error, show you are currently in compliance, and show what remedial measures you have taken to keep there from being a repeat, the MAC will accept your corrective action plan (CAP) and will reinstate your Medicare number, as things stand currently.

Halifax Whistleblower Claims Hospital Overbilled Medicare

The U.S. Department of Justice has joined a whistleblower suit filed against Halifax Hospital by the hospital’s director of physician services, according to the Daytona Beach News-Journal.

The U.S. Department of Justice filed its part of the lawsuit on Friday. It claims that Halifax Health defrauded the federal government by submitting thousands of false claims for Medicare and Medicaid payments worth millions of dollars. By filing, the U.S. Department of Justice hopes to recover millions of dollars in Medicare and Medicaid payments that it says were made in error to Halifax.

Elin Baklid-Kunz filed a lawsuit against Halifax in 2009. As a whistleblower, he could be awarded a percentage of whatever the government recovers. Generally, whistleblowers can be awarded 25 percent to 30 percent of the recovery. He claims Halifax overbilled Medicare by inappropriately admitting patients and had financial arrangements with some of its doctors that violated a federal anti-kickback law.

The federal Stark Law prohibits Medicare and Medicaid payments for hospital services that are prescribed by doctors who have profit-sharing agreements with the hospital. The law was made to ensure that referrals are made for medical reasons only, without financial motives.

However, according to the lawsuit, Halifax had agreements with its doctors that gave them a financial incentive to generate hospital revenues.

The Justice Department’s lawsuit focuses on doctors’ contracts, claiming that Halifax administrators “could not have reasonably concluded” the agreements to pay bonuses to doctors did not violate the Stark Law. Neurosurgeons at Halifax received generous incentive compensation that boosted their based salaries by hundreds of thousands of dollars. These neurosurgeons referred patients to Halifax and, between 2004 and 2010, Halifax charged Medicare more than $35 million for neurological services, the suit states. Each neurosurgeon individually generated over $2 million in profits for Halifax Hospital in 2009, according to the suit. The Justice Department claims a similar pattern existed with the hospital’s seven oncologists.

For more information on similar legal matters, visit www.TheHealthLawFirm.com.

Responding to a Medicare Audit – Practice Tips

Although you may speak of a “routine” Medicare audit, there is really no such creature. This is like saying you have a “routine IRS audit.”  The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.

Having too many claims for level five CPT codes might, for example, cause you to be audited.  Having multiple claims submitted for the same date of service, may cause you to be audited.  Submitting claims for CPT codes outside of your medical speciality area, might cause you to be audited.  Having the dollar amount of claims greater than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Having a greater number of claims submitted than the average for a similar health practitioner in the same geographical area of the country, may cause you to get audited.  Filing claims for services that are on the Office of Inspector General’s (OIG) annual work list may cause you to be audited.

“Routine” audits, those that do not involve some suspicion of false billings or fraudulent activities, should, nevertheless, be treated extremely seriously and the physician, group or health provider being audited should give the matter personal attention.  Examples of some contractors that may be involved in “routine” audits include DelMarva Foundation, Palmetto GBA, Cigna GBA, or First Coast Service Options, Inc.

However, if the audit letter or audit notice is from a Zone Program Integrity Contractor (ZPIC), such as SafeGuard Services, LLC, or AdvanceMed, the matter is very serious and should not be treated as a routine audit.  If the “audit” comes in the form of a subpoena, then it is extremely serious.  If any FBI agent or OIG special agent is involved in it, then it is extremely serious.  In any of these three cases, an experienced health attorney should be retained immediately.

Even on a “routine” audit, given the possible consequences, we recommend you immediately retain the services of an experienced health attorney to guide you through the audit process, to communicate with the auditors, and to be prepared if it is necessary to challenge the audit findings.

These are some of the items actions we recommend you take and which we take in representing a physician or other health provider in responding to a Medicare audit.

1. All correspondence from Medicare, or the Medicare contractor, should be taken seriously.  Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request.  Avoid the temptation to delegate this as a routine matter to an administrative employee.

2. Read the audit letter carefully and provide all the information requested in the letter.  In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you.

3. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.  Include any diagnostic tests and other documents from the chart that support the services provided.  Many practices document the medications and immunizations given to the patient in a separate part of the chart and not in the progress notes; all documents, the complete record, should be provided to the auditor.  Remember that even other physicians records obtained as history, including reports, consultants and records from other physicians or hospitals, should also be included.  Consent forms, medical history questionnaires, histories, physicals, other physicians’ orders, all may be a crucial part of the record and should be included.  If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.

4. Make sure all the medical records are legible and legibly copied.  If the record is not legible, have the illegible record transcribed and include the transcription along with the hand-written or illegible records.  Make sure than any such transcriptions are clearly marked as a transcription with the current date it is actually transcribed.  Label it accurately.  Do not allow any room for there to be any confusion that the newly transcribed part was part of the original record.

5. If your practice involves taking or interpreting x-rays or other diagnostic studies, include these studies.  They are part of the patient’s record.  If the x-rays are digital, they can be submitted on a compact disc (CD).

6. Never alter the medical records after a notice of an audit.  However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete.  Altering a medical record can be the basis for a fraud claim including criminal penalties.

7. Make sure each page of the record is copied correctly and completely.  If the copy of the record has missing information because it was cut off, the original needs to be recopied to ensure it includes all the information.  Don’t submit copies that have edges cut off, have bottom margins cut off, are copied slanted on the page, or for which the reverse side is not copied.  Reduce the copied image to 96% if necessary to prevent edges and margins from being cut off.

8. Make color copies of medical records when the original record includes different colored ink of significance.  Colors other than blue and black rarely copy well and may be illegible on standard photocopiers.

9. Include a brief summary of the care provided to the patient with each record.  The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area.  Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared.  Label it accurately.  Do not allow any room for there to be any confusion that this new portion was part of the original record.

10. Include an explanatory note and any supporting medical literature, clinical practice guidelines, local coverage determinations (LCDs), medical/dental journal articles, or other documents to support any unusual procedures or billings, or to explain missing record entries.  See item 9 immediately above.

11. When receiving a notice of a Medicare audit, time is of the essence.  Be sure to calendar the date that the records need to be in to the auditor and have the records there by that date.  Note: the due date is not the last date on which you can mail the records but rather is the date that the records must be at the auditor’s office.

12. Any telephone communication with the auditor should be followed up with a letter confirming the telephone conference.

13. Send all communications to the auditor by certified mail (or express mail), return receipt requested so you have proof of delivery.

14. Properly each copy of each medical record you provide and page number everything you provide the auditors, by hand, if necessary. Medical record copies often get shuffled or portions lost or damaged during copying, storage, scanning or transmission.

15. Keep complete, legible copies of all correspondence and every document you provide.  When we provide records to a Medicare auditor, we make a complete copy for the auditor, for the client, for us (legal counsel) and two for your future expert witnesses (to challenge any audit results) to use.

16. Consult an experienced health law attorney early in the audit process to assist in preparing the response.

The above check list is by no means comprehensive.  Nor do we mean to suggest that you should respond on your own.  The above is illustrative of the many actions that should be taken to help protect your interests when you are subjected to a Medicare audit.

Visit our website at www.TheHealthLawFirm.com for more information on Medicare audits, ZPIC audits, health care subpoenas, Medicare and Medicaid search warrants and Medicare and other federal administrative hearings.