Medicare Post-Payment Audits

January 2014Articles Allegheny County Medical Society Bulletin

In the previous installment, we looked at how to respond to an audit from Highmark Blue Cross Blue Shield. For most physician practices, Medicare Part B (i.e., “traditional” Medicare) remains one of the two or three largest payers. A chart request or refund demand from Medicare can be unsettling, but it can be managed to minimize your potential liability. Much of the substantive advice mirrors the best practices for responding to a private payer audit, but with Medicare there are more government agencies and contractors involved and many more levels of appeal. Given the broad applicability of the False Claims Act and its draconian penalties, the stakes are much higher as well.

We recommend keeping an acronym glossary handy. Medicare is administered by federal contractors known as Fiscal Intermediaries (FIs) for Part A services, generally hospital care, and Medicare Carriers for Part B services, including physician claims. In Pennsylvania, the Medicare Carrier is now Novitas Solutions, a subsidiary of the Florida Blues plans which purchased the Medicare claims processing business from Highmark Medicare Services in 2011 but retained much of the previous staff located in Camp Hill, Pa. Novitas also is referred to as a Medicare Administrative Contractor (MAC), not to be confused with Recovery Audit Contractors (RACs), who are tasked with identifying overpayments and underpayment on a post-payment basis. All these entities are collectively referred to as “contractors.”

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