I represent many health care providers. I also represent health care businesses respond to CMS, Cardinal Health and or Novitas Solutions improper medicare medicaid audits and claw backs. My clients email me these audit letters that are generated through AI data dumping and crunching. This process is authorized through the federal OIG regulations that give the auditing companies a financial stake in the settlements they produce. Authority is secured annually through the regulations and centralized OIG office. https://oig.hhs.gov/fraud/medicaid-fraud-control-units-mfcu/data-mining.asp
High revenue entities with high volume and typically use the same billing codes, procedures are targeted. Statistically, that entity looks like an outlier. My clients have to spend huge amounts of time and staff energy investigating and responding to the paper work requirements of the audit request. Prior authorizations, medical records, signatures, receipts for every visit for each procedure code, for each patient must then be tracked down and located and attached to the audit response. Don’t forget, the dates of service could be two years old.
Recently, UnitedHealthcare filed a pre-emptive law suit to stop CMS from downgrading its star ratings “based upon a single phone call that lasted less than [10] minutes.” CMS determines star ratings for MA plans based on several clinical quality and customer service metrics. The agency rates plans’ call center adequacy by placing test calls from secret shoppers. For a call to be included in CMS’ sample, the test caller must ask an introductory question, and the customer service representative must respond, UnitedHealthcare said in its lawsuit. The company alleged CMS is including a call in its ratings where the required introductory question was not asked.
“Because 100% success is required to be awarded 5 Stars on the call center measure, CMS’ decisions regarding whether and how to score each call included in the study can have a material impact on plan performance on the call center measure specifically, as well as on a plan’s overall Star Rating,” UnitedHealthcare’s attorneys wrote. UnitedHealthcare asked the court to have CMS throw out the disputed call and require CMS to recalculate its star ratings before the ratings are published Oct. 10. Elevance Health previously challenged the inclusion of a phone call in its star ratings. The company alleged the disputed test call never connected and said it lost $190 million in bonus payments as a result of the call. CMS eventually ruled in Elevance’s favor to remove the call from its calculations.
Call me to discuss your company’s state or federal MCS OIG audit request.
