Surviving a CMS Audit One Region’s Experience
Raymond L. Fowler, M.D., FACEP Professor of Emergency Medicine Co-Chair of the Section on EMS, Disaster Medicine, and Homeland Security -------------------- Chief of Operations The Dallas Metropolitan BioTel System -------------------- Attending Emergency Medicine Faculty Parkland Memorial Hospital
Medicare Established in 1965 in the Johnson Administration
Medicare Originally estimated to cost $26 billion in 2003 Actually cost in 2003 approximately $240 billion
Medicare A “fee-for-service” system Has set standards for industry reimbursement (DRG, “Usual and Customary”) EMTALA
Medicare / Medicaid Utilizes regional contracting agencies to provide payments as well as auditing compliance In Texas, it is a company called “Trailblazer”
Medicare / Medicaid Payers have the authority to conduct periodic audits They “pay first” and “audit later” Have the authority of law to require repayments and to levy fines
City of Dallas Approximately late 2009 were notified of an audit to be conducted A “whistleblower” in the city government notified CMS of concerning practices by the billing company An audit ensued
City of Dallas Billing company in place for fifteen years…trusted… Custom written ePCR No “internal compliance” program for the City Approximately 4 year audit period
City of Dallas ~90,000 accounts filed with Medicare during this period ~60,000 accounts PAID by Medicare during this period ~30,000 accounts denied payment as “unnecessary” – all 911
City of Dallas Audit 44 Total Charts were pulled 60,000 ÷ 44 = 1,363 “factor”
EMS Medicare Billing BLS ALS 1 ALS 2 Standards all well-defined
City of Dallas Billing company had billed everything as “ALS 1” without the City’s knowledge or approval Everything was dispatched Emergency
City of Dallas Hired outside representation Audit overseen by the City Attorneys Met with the Department of Justice
City of Dallas Medicare’s review of the 44 charts: 20 of them should not even have been paid!
City of Dallas Medicare’s estimated repayment from the City: 20 x $320 x 1363 = >$8,500,000 PLUS TRIPLE FINES!!!
City of Dallas Medicare’s estimated repayment from the City: $8,500,000 + $25,500,000 =
I should add, at this point: They weren’t kidding And, they had the DOJ conducting the investigation
City of Dallas Their audit Elderly woman from a nursing home on dialysis, temp 103, pulse 130, in shock EMS Transport Unnecessary
City of Dallas Our audit All 44 transports necessary 20 should have been billed at the BLS Level
City of Dallas Difference in reimbursement for BLS vs. ALS 1 from Medicare $20
City of Dallas Our computed repayment: 20 x $20 x 1363 = ~$600,000 PLUS TRIPLE FINES!!!
City of Dallas We offered them a check that day for ~$600,000 based upon our own audit Their reply: “Not enough commas”
City of Dallas Negotiation period of about a year followed Ultimately settled for ~$2,500,000
City of Dallas Billing Company had only a $1,000,000 liability policy That company was fired Every other agency in the area that used that company was also audited and paid fines
We were asleep at the wheel
Medicare Billing Requirements If you bill a “payer”, YOU and NOTyour billing company are the responsible party to assure billing accuracy… CMS holds YOU accountable! You can’t pass the blame!
Medicare Billing Requirements You are required BY LAW to have an internal billing compliance program
Medicare Billing Requirements • You must be very careful • with instructions that you • give the billing company because • they may blame mistakes on you • How do you dispatch? • Do you meet CMS standards • for each billing level?
Medicare Billing Requirements Blind trust of you billing company can be very, very expensive
To Do, Upon Returning Home: • Check out your billing company • What instructions have you • given them? • Check out your compliance • program carefully
STEAL GOOD IDEAS FREELY! Find a example of an EMS agency with an excellent compliance program Example: MedStar in Fort Worth
Remember • Compliance has many parts: • Dispatch • Response • Treatment • Documentation • Billing Accuracy • Filing, then refiling
And, especially…. Perform periodic audits of your entire system to determine your accuracy… …and your risk…
It may cost more up front…. …but it’s a heckuva lot cheaper than what might happen on the back end…
Thank you for your kind attention…