The COVID-19 pandemic has suspended almost all normal medical operations, both from the practice side and the insurance payer side. Some rules have been waived and special billing codes issued.
The crisis should not, however, cause you to ignore documentation guidelines. You need to continue to document correctly for the level of service you’re billing. Avoiding scrutiny and adverse audit findings is important, regardless of external considerations. Though adding stress to your day isn’t my intent, it’s the wise person who recognizes threats and responds appropriately.
Targeted Probe and Educate
The first level of scrutiny that Medicare uses is called “Targeted Probe and Educate” (TPE). This program uses claims data to identify physician outliers. According to Medicare:
- TPE is intended to increase accuracy in very specific areas. MACs [Medicare Administrative Contractors] use data analysis to identify:
- providers and suppliers who have high claim error rates or unusual billing practices [emphasis added], and
- items and services that have high national error rates and are a financial risk to Medicare.
- Providers whose claims are compliant with Medicare policy won’t be chosen for TPE.1
If you’re identified as a TPE target, you’ll receive a request from your MAC to submit a sample of 20 to 40 charts for review. If the review finds adequate documentation, the process is closed.
This may happen if a provider is an outlier because of a specialty practice. For instance, a retina surgeon who has few routine new patients will tend to have a higher percentage of complex patients, and thus may bill more Evaluation and Management (E/M) Level 4 and 5 exams, putting the surgeon at risk for TPE evaluation. If those exams are poorly documented, the MAC will start the “educate” process of TPE.
A round of education is followed by a repeat audit. If the documentation has improved, the process ends. If there’s no improvement, the MAC can decide to repeat the process or refer the provider for “additional investigation.” This may include a fraud or abuse investigation.
The Comprehensive Error Rate Testing (CERT) process is part of Medicare’s required reporting to Congress. Medicare explains the process accordingly:
CMS implemented the CERT Program to measure improper payments in the Medicare FFS Program. Under the CERT Program, a random sample of all Medicare FFS claims [emphasis added] are reviewed to determine if they were paid properly under Medicare coverage, coding, and billing rules. Once the CERT Program identifies a claim as part of the sample, it requests via a faxed or mailed letter the associated medical records and other pertinent documentation from the provider or supplier who submitted the claim.
If there is no response to the request for medical records, the CERT may also make a telephone call to solicit the documentation. Once the documentation is received, it is then examined by medical review professionals to see if the claim was paid or denied appropriately. In this type of audit, the provider receives usually a single page request for one claim. By promptly responding to the record request, the provider will support the claim and usually there is no feedback. It is important to note that CERT data is used in reporting billing compliance to Congress. If a provider ignores a CERT record request, the payment is retracted and the claim is reported as “no documentation” [emphasis added]. In the congressional report, “no documentation” is not further subdivided and may be interpreted as a fraudulent claim.2
You need to be sure your billing department responds to CERT requests promptly to prevent further scrutiny and having it become part of an accurate congressional report.
Identifying improper payments
Another Medicare audit process is the Recovery Audit Contractor audit (RAC). Medicare’s stated goal is:
… to identify improper payments made on claims of health care services provided to Medicare beneficiaries. Improper payments may be overpayments or underpayments. Overpayments can occur when health care providers submit claims that do not meet Medicare’s coding or medical necessity policies. Underpayments can occur when health care providers submit claims for a simple procedure but the medical record reveals that a more complicated procedure was actually performed.3
This process involves pulling a number of claims and reviewing the documentation for correct coding. If the auditor believes a claim was paid incorrectly, you get an opportunity to defend it in a physician-to-physician telephone call. If the auditor is still unconvinced, your MAC will be alerted with a recommendation to retract payment. You can then appeal directly to your MAC.
A pattern of irregular billing or a whistle-blower complaint could trigger a Medicare audit. If the audit uncovers poor documentation or billing irregularities, you could be charged with fraud or abuse. Serious civil and criminal penalties can follow either charge.
Bottom line: Remain calm
These are extraordinary times, and we’re all doing our best to serve patients. However, that is no excuse to ignore your hard-learned lessons in documentation. The basic rule still applies: If you didn’t write it down, you didn’t do it. RS
1. Centers for Medicare and Medicaid Services. Targeted Probe & Educate. https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Targeted-Probe-and-EducateTPE. Updated December 16, 2019. Accessed April 30, 2020.
2. Centers for Medicare and Medicaid Services. Comprehensive Error Testing Rate Fact Sheet: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf. Updated April 2017. Accessed April 30, 2020.
3. Centers for Medicare and Medicaid Services. CMS announces new recovery audit contractors to help identify improper Medicare payments. https://www.cms.gov/newsroom/fact-sheets/cms-announces-new-recovery-audit-contractors-help-identify-improper-medicare-payments. Updated October 6, 2008. Accessed April 30, 2020.