Medicare and Medicaid Audits and Appeals 2017

Medicare and Medicaid Audits and Appeals 2017

The Medicare and Medicaid programs employ a number of contractors to conduct audits of medical providers.  These contractors include the Medicare Administrative Contractors (MACs), the Zone Program Integrity Contractors (ZPICs), Comprehensive Error Rate Testing Contractors (CERT), Recovery Audit Contractors (RACs), and in the case of Medicaid in Florida, the Agency for Health Care Administration (AHCA), the Medicaid Fraud Control Units (MFCU), and the Medicaid Audit Contractors (MICs). 

The Medicare Administrative Contractor in Florida is First Coast Service Options (FCSO).  FCSO administers the Medicare program payments in Florida for Parts A and Part B.  In addition to processing claims for payment submitted by medical providers, FCSO also conducts medical review audits of claims submitted.  These audits can be either prepayment reviews, or post-payment audits. 

The Zone Program Integrity Contractor (ZPIC) in Florida is Safe Guard Services (SGS).  SGS is tasked with identifying potential fraudulent claims and providers.  As part of its benefit integrity function, SGS, along with its related contractor, IntegriGuard, conducts prepayment review audits of Medicare providers. 

The CERT contractors conducts post-payment audits to determine the percentage of Medicare claims submitted that are erroneous, that is, that should not have been paid.

Recovery Audit Contractors (RACs) are private companies under contract with the Centers for Medicare and Medicaid Services which have been tasked with identifying Medicare overpayments and underpayments and returning Medicare overpayments to the Medicare Trust Funds. RACs review claims submitted by health care providers and suppliers in an attempt to identify improper payments. Because RACs receive a portion of the improper payments they identify, the RACs are highly motivated to identify overpayments and other improper payments.

 

The RAC program began as a three-year demonstration program in 2005 in California, Florida and New York, the three states with the highest Medicare expenditures. In 2007, the program expanded to include Massachusetts, South Carolina and Arizona. The purpose of the RAC demonstration program was to determine whether the use of RACs would be a cost-effective way to identify and correct improper Medicare payments.

 

HPP Management Group, Corp. represent and defend providers and suppliers in all types of Medicare, Medicaid and other third party payer audits, appeals and controversies. We have the knowledge and experience to assist providers and suppliers in responding to audit requests in order to minimize the number of initial denials, as well as to successfully appeal any improperly denied claims. Please do not hesitate to contact us to discuss your particular situation.

For details please call 305-227-2383 or 1-877-938-9311 or  email:    psilben@hppcorp.com