MIC, MAC & RAC –
Oh My!
1
THE WORLD OF
MEDICAL CLAIMS AUDITING
HealthCare Management Consultants 2013
TRANSLATION, PLEASE
2
ACRONYM
PROGRAM NAME
MIC
Medicaid Integrity Contractor
MAC
Medicare Administrative
Contractor
RAC
Recovery Audit Contractor
OREGON CONTRACTOR
HMS
Noridian Healthcare Solutions
Health Data Insights
OTHER AUDITING ENTITIES
ZPIC
Zone Program Integrity
Contractor
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NCI, Inc
TRANSLATION, PLEASE
3
FEDERAL AGENCIES
ACRONYM
PROGRAM NAME
DOJ
Department of Justice
OIG
Office of Inspector General
FBI
Federal Bureau of Investigation
HEAT
Health Care Fraud Prevention & Enforcement Action Team
OTHER MEDICAID AUDIT ENTITIES
MEDICAID
RAC
Medicaid RAC
MFCU
Medicaid Fraud Control Unit
MIP
Medicaid Integrity Program
OMIG
State Office of Medicaid Inspector General
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TRANSLATION, PLEASE
4
OTHER CMS AUDITS
ACRONYM
CERT
PROGRAM NAME
CONTRACTOR
Comprehensive Error Rate Testing AdvanceMed/Livanta
OTHER AUDITING ENTITIES
Other local or national insurance carriers
Also, your MAC or any other carrier can initiate an audit based on review of
individual claims or whistleblower report
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MIPS & MICS
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 These are both Medicaid programs. The MIP was created
under the Deficit Reduction Act of 2005. MIP is intended to
help reduce provider fraud, waste and abuse in the Medicaid
program.
 CMS developed the Comprehensive Medicaid Integrity Plan
which oversees the MIP through the MIC.
 There are 3 primary MICs:
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Review MICs to analyze Medicaid claims data looking for potential
provider fraud, waste, and abuse
Audit MICs audit provider claims for overpayment
Education MICs furnish provider education
 CMS is responsible to hire the MIC contractors and to support
the program in combating fraud and abuse
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WHAT THE MIC AUDITS LOOK FOR
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 Incomplete documentation
 Conflicting documentation
 Improper coding
 Duplicate billing
 Providing services that aren’t medically necessary
 Patient privacy breaches
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MAC
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 The MAC is the regional Medicare carrier. In Oregon, the MAC is
represented by Noridian Healthcare Solutions and the majority
of Medicare claims are submitted directly to Noridian.
 The MAC puts claims through a pre-payment edit, that includes
all LCDs, NCCI edits, MUE edits, etc. If they pass the edit, then
the MAC employs formulas to determine and administer
payment.
 Noridian works in conjunction with contractors conducting the
CERT audit, which is an annual random audit of a statistically
valid volume (about 50k) of Medicare FFS claims.
 Noridian also provides education through a variety of resources.
HealthCare Management Consultants 2013
MAC AUDITS
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 The MAC can audit any claim at any time, but does not audit
all claims
 Focus on claims with the potential to be non-covered or
incorrectly coded
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High volume of services
High cost
Dramatic change in frequency of use
High risk problem-prone areas
 MAC notifies provider in writing prior to beginning provider-
specific audit. Notice will indicate if this will be a pre or post
payment review and the reason for the audit. Notice will be
sent by certified mail.
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CERT CONTRACTORS/ RESPONSIBILITIES:
OREGON
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 AdvanceMed, a Program Safeguard Contractor (PSC), administers
the activities of the CERT program. As the CERT Review
Contractor, AdvanceMed is responsible for:
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Selecting a random sample of claims that have been received by each Medicare
contractor every month.
Reviewing the selected claims and associated medical record documentation to
determine if the claim was appropriately adjudicated according to Medicare
regulations/guidelines.
 Livanta’s role as the CERT documentation contractor is to
streamline the record request and receipt functions.
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The CERT Documentation Contractor is responsible for:
Requesting and receiving medical record documents;
Maintaining a document tracking system;
Providing a website for updating supplier addresses and contact information;
Scanning the medical records into a retrieval system; and
Operating a call center to answer contractor and supplier questions regarding CERT
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CERT AUDIT FINDINGS 2012
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TOP 20 SPECIFIC SERVICE TYPES:
HIGHEST IMPROPER PAYMENTS: PART B
1
Chiropractic
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Subsequent Inpatient Care
2
Initial Inpatient Care
12
Dialysis Services
3
Hospital: Critical Care
13
MRI/MRA
4
Lab Tests – Blood Counts
14
Other Tests
5
Lab Tests, other (non-MC fee schedule) 15
Established Office Visit
6
Minor Procedures
16
ED Visits
7
Oncology: Radiation Therapy
17
Lab Tests (MC Fee Schedule)
8
NP Office Visits
18
Ambulatory Procedures: Skin
9
Nursing Home Visits
19
Ambulance
10
Specialist: Psychiatry
20
Other Drugs
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THE RAC
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 The mission of the RAC is to reduce improper Medicare over
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payments.
Their methodology is data mining based on claims data.
Based on this methodology, they also identify underpayments.
RACs investigate specific measures identified and approved by
Medicare
RAC contractors are paid on a contingency basis –
Contingency fees range from 9.0% - 12.5% for all claims except
DME – Contingency for DME is from 14.0% to 17.5%
The RAC may request up to 500 records every 45 days, which
poses huge operational concerns for provider offices
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RAC COLLECTIONS: 2011
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 Identify & correct $939.3m in improper payments
 $797.4m overpayments
 $141.9m underpayments
 CMS spent $129.4m to operate the Medicare FFF
Recovery Audit Program.
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$89.9m paid in contingency to RAC contractors
$47.5 paid in administrative costs
 Net returned to Medicare Trust Fund FY 2011: $488.2
HealthCare Management Consultants 2013
RAC MEASURES
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 As of 09/01/2013, there 664 RAC measures; 69 of them added
this year
 New measures for 2013 targeted at Physician/NPP
professional services include:
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Medically unlikely billed dosages of drugs and biologicals
Incorrect billing of drugs and biologicals
Excessive units of new patient visits
Outpatient hospital stays billed as inpatient
Post-payment review of therapy claims above $3,700 threshold
Other specialty-specific measures involving Urology, Radiology,
Lab/Pathology, Ophthalmology, and Interventional Radiology.

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RAC TRANSITIONS 2013
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 Medicare has begun to transition to the new Medicare FFS
Recovery Audit Program. A Request for Quote has been issued.
 The new program with have 4 Medicare A/B Recovery Contractors,
1 DME Recovery/Contractor, and 1 Home Health/ Hospice Recovery
Contractor.
 ADR requests are expected to decline beginning in June;
prepayment and postpayment reviews are expected to continue
without decline
 There is also an ongoing Prepayment Review Demonstration
project focusing on seven error-prone states. The intent is to lower
the error rate by preventing improper payment rather than trying
to identify and recoup overpayments after payment has been
made.
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ZPIC
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 ZPIC’s role is to identify potential Medicare fraud within a service area
by review of past and pending claims
 ZPIC’s reviews are not random - the provider is under investigation for
potential fraud
 Investigations are initiated by:
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Data analysis
Complaints
Referral from other agency (MAC, RAC, etc)
 Auditor may come onsite
 May conduct interviews with beneficiaries or provider’s employees,
etc.
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WHAT ZPIC AUDITS FOR
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 Identify areas of potential errors (i.e., noncovered or
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incorrectly coded) that pose greatest risk.
Establish baseline data for comparison
Identify need for LCD and/or education
Identify high volume services that are overutilized
Identify program errors or specific providers for possible fraud
investigations
Determine if findings by other MC auditing agencies represent
significant problem areas
ZPIC audits to confirm fraudulent behavior, not to discover it
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OIG
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 The OIG has been supervising audits and fraud/abuse
investigations since 1993. These are not limited to
Medicare – the intent is to minimize loss in all
government programs.
 The OIG may work an investigation alone or in
conjunction with other agencies (i.e., as part of a HEAT
investigation)
 The OIG has the ability to determine fines, and to exclude
individuals and entities who have engaged in fraud from
Medicare/Medicaid/other federal health care programs.
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OIG ENFORCEMENT ACTIONS 2012
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 Opened 1,131 new criminal health care fraud
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investigations against 2,148 potential defendants
2032 investigations already opened, involving 3410
potential defendants; filed charges in 452 cases involving
892 defendants
826 individuals convicted
885 new civil investigations opened
1023 civil investigations pending at year end

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Per OIG Annual Report for 2012
2012 RESULTS
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 Monetary Settlements:
 Won or negotiated $3.0 billion in judgments & settlements
 Exclusionary Actions
 Excluded 3,131 individual and entities
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Per OIG Annual Report for 2012
OIG AUDIT PLAN 2013
(MEDICARE PART A & B: SPECIFIC TO PHYSICIANS)
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 Noncompliance with assignment rules and excessive
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billing of beneficiaries
Error rate for incident-to services performed by nonphysicians
Place of service coding errors
Potentially inappropriate E/M services in 2010
E/M services: use of modifiers during global surgery
period
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HEAT TASK FORCE
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HEAT’s MISSION
 To gather resources across the government to help prevent waste,
fraud, and abuse in the Medicare and Medicaid programs.
 To crack down on the people and organizations who abuse the system
and cost Americans billions of dollars each year.
 To reduce health care costs and improve quality of care by preventing
fraudsters from preying on people with Medicare and Medicaid.
 To highlight best practices by providers and organizations dedicated to
ending waste, fraud, and abuse in Medicare.
 To build upon the existing partnerships between HHS and DOJ to
reduce fraud and recover taxpayer dollars.

HealthCare Management Consultants 2013
Excerpt Stop Medicare Fraud website
WHY AUDITS ARE NECESSARY
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 Medical claims payment program is on the honor system
– only about 5% of submitted claims are reviewed
 The payment system is a target for deliberate, organized
and systematic fraud
 A small amount of deliberately fraudulent entities
responsible for a significant amount of dollars lost in the
Medicare/Medicaid program
 May 2013: HEAT coordinated nationwide takedown – 89
participants in 8 cities involving $223 million in false
billings
HealthCare Management Consultants 2013
FRAUD EXAMPLE:
MAY 2013 HEAT “TAKEDOWN”
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Miami: 25 defendants, $44m in home health care fraud
Baton Rouge: 5 defendants, $51m in home health care fraud
Houston: 2 defendants, $8.1m in home health care fraud
LA: 13 defendants 23m , including 3 defendants & $8.7m in
DME fraud
Detroit: 18 defendants, $49m in medically unnecessary
services
Tampa: 9 defendants, pharmacy fraud, money laundering,
billing for surgeries not performed
Chicago: 7 defendants with various health care fraud schemes
Brooklyn: 4 defendants; $9.1m in false claims & 3 defendants,
$15m in unlicensed massage therapy billed as physical
therapy
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MAY 2013 “TAKEDOWN” INDICTED
AS PARTICIPANTS
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 Physicians (9)
 Nurses
 Paramedics
 Radiographer
 Home Health agency
 Community mental health center
 Social worker
 Physician Assistant
 Therapists
 Health care clinics & Rehab facility
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2013 FRAUD CASE STATISTICS
(so far)
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 28 states
 145 settled cases
 28 publicly reported cases pending
Reported per HEAT
September 2013
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THE AFFORDABLE CARE ACT &
FRAUD INVESTIGATION
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 The Affordable Care Act, the health care law, takes powerful steps toward combating
health care fraud, waste, and abuse. The government has recovered a record-breaking
$10.7 billion in recoveries of health care fraud in the last three years.
 Tough new rules and sentences for criminals: The law increases federal sentencing
guidelines for health care fraud by 20-50% for crimes with over $1 million in losses.
 Enhanced screening: Providers and suppliers who may pose a higher risk of fraud or
abuse are now required to undergo more scrutiny, including license checks and site
visits.
 State-of-the-art technology: To target resources to highly suspect behaviors, the
Center for Medicare & Medicaid Services now uses advanced predictive modeling
technology.
 New resources: The law provides an additional $350 million over 10 years to boost
anti-fraud efforts

HealthCare Management Consultants 2013
Excerpt Stop Medicare Fraud website
MEDICARE AUDIT GOAL by 2012
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 Reduce overall payment errors by $50 billion
 Cutting Medicare fee-for-service error rate by 50%
 Recovering $2 billion in improper payments
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S.1012: MEDICARE AUDIT IMPROVEMENT
ACT OF 2013
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 Introduced in the Senate May 22, 2013
 Assigned to committee same date
 Predicted: 1% chance of getting past committee; 0% chance of
being enacted
 Highlights:
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Would establish a combined annual limit of audit requests from
federal agencies
Provide for auditor penalties when appeals are successful
Publish RAC performance information, including audit rates, denials,
appeals outcome and performance reviews
Physician review for each RAC claim denial if denial determination is
made by a non-clinician
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RISK FACTORS: MYTH vs REALITY
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Myth:
1a.
1b.
1c.
2.
3.
Only large groups get audited
Only urban practices get audited
Only specialists get audited
“I’ve never been audited”
“An reasonable physician would understand my documentation
I can explain my position to the auditor and prevail”
Reality
1a.b.c Provider risk is based on provider practice patterns, regardless
of the size, location, and type of practice
2.
Any request by a carrier for a chart note is an audit – if you’ve
submitted a chart note at the carrier’s request, you’ve been audited
3.
Hmmmmmmmm
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RISKY BEHAVIOR
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 Reporting high volume of high level codes without the ability to support them
 High volume unsupported or unbelievable time coding
 Inappropriate use of prolonged service codes
 Inappropriate application of “incident to” or “shared/split services”
 Inappropriate use or authentication of “scribes” or authentication of scribe
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role
Billing a payable code instead of the non-covered service actually
accomplished
Billing for ancillary diagnostic services without medical necessity
Billing for procedures or ancillary diagnostic services and manipulating the
diagnosis code to assure coverage
Billing time-coded psych services without documenting the time in the chart
note
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RISKY BEHAVIOR
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 Specialty practice: every new problem is a new patient encounter
 Billing higher for work comp because of the “psycho-social considerations”
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involved and the support required
Every surgical case is billed with a modifier 22
Every post op encounter is a billed with an E/M code and a modifier 24
Every pre-op is billed (even though the decision for surgery was made 2
weeks ago) and there is no medical necessity to support the service
Unbundling services
Billing for services not accomplished
Billing “never” events – like amputation on the same body part – multiple
times
Churning
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RISKY BEHAVIOR:
EHR VULNERABILITY
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 Cloning
 Automatic “pull through” documentation
 “Click” documentation
 Contradictory documentation
 Unreviewed/incomplete documentation (VRS errors)
 Garbled documentation
 Poor documentation
 Authentication (not signed/no title, etc)
 Automatic inclusion “one size fits all” time-coding statement
 Time coding doesn’t match imbedded system time stamps
 Printed chart notes don’t contain patient identifier on each page
 Medical Necessity not supported
HealthCare Management Consultants 2013
WOULD YOU REIMBURSE THIS?
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 Excerpt from exam portion of E&M: “His liver alert and
oriented x3 shows a deficit of cognitive function are
thought physical psychosomatic eye pupils equal and
rectal exams are normal her eczema with inflammation”.
 Excerpt from HPI: “She has insomnia-she takes her
temazepam at HS-she is gestating at least 5 hours at
night”
Excerpt from Noridian Part B News, July 2011
Notes reviewed in a CERT audit
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Hi, I’m a 99214…….Really?
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CC: follow-up
HPI: John returns, feeling great. No chest pain, no shortness of breath. No
problems with meds; going to Arizona for the winter.
ROS: All other systems negative
PFSH: Meds reviewed and updated – no changes; still smoking
Exam:
Vital Signs: BP 120/80; Ht 6ft; Weight 205
General Appearance: NAD
Psych: Normal mood and affect
Labs: Normal
Assessment: Diabetes, Hypertension, Hypercholesteremia, all stable
Plan: No changes, follow-up in Spring after return from Arizona
HealthCare Management Consultants 2013
TIME CODING STATEMENTS
(that don’t work)
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 I spent more than half of a 25 minute visit reviewing the
management and treatment options for the conditions
listed above.”
(stated on every patient encounter for the day)
 “More than half of a 45 minute visit spent face to face
with the patient.”
(what did they do for the rest of the encounter?)
HealthCare Management Consultants 2013
WHAT IS AN AUDIT?
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 A request from a carrier for a chart note in order to make
payment
 A request from an auditing entity to return money for an
individual or multiple claim based on identified error
 A request from an auditing entity (i.e. OIG) for a volume of
specific chart notes for review based on identified issues
 Appearance of a sanctioned auditor in the office with a request
for specified chart notes for review
 Based on the situation, the audit may be either a pre-payment or
a post-payment review
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POTENTIAL MAJOR AUDIT CONSEQUENCES
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 Return of overpayments
 Extrapolation
 Fines - up to treble damages per occurrence
 Exclusion from Medicare – and all other federally funded
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carriers (Medicare HMO, Medicaid, TriCare, etc)
Development of a CIA (Corporate Integrity Agreement)
Potential compromise of practice financial viability
Criminal charges, if deemed appropriate
IRS issues, if deemed appropriate
Stripes?
HealthCare Management Consultants 2013
FREQUENT AUDIT TRIGGERS FOR
CREDIBLE MEDICAL PRACTICES
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TYPE OF SERVICE
PROBLEM
IDENTIFIED BY
E/M Services
Consistent Over-Coding
Provider Profile compared to
national by-specialty profile
Surgery
Unbundling services
NCCI edits
Coding Guidelines
Inappropriate use of
time coding
Chart review
Coding Guidelines
Inappropriate use of
Chart review
Incident to or shared/split
services
Coding Guidelines
Cloning
Chart review
Clinical Guidelines
Churning
Comparison to clinical
standards of care
All of the above
HealthCare Management Consultants 2013
Whistle blower
WHAT ELEVATES YOUR RISK
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 Misunderstanding of coding guidelines
 Misunderstanding of levels of service application
 “Half-knowledge” or lack of knowledge
 Mistake by provider or staff
 “Don’t know, don’t want to know, won’t change”
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REDUCING YOUR RISK: PREVENTION
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 Oversight: Develop, Implement & follow a credible Compliance Plan
 Operational policies and procedures, including:
 Development of an Audit/Provider Education Team
 Assign role of internal “External Audit Expert”
 Receipt & Processing Audit Requests
 Development of electronic reports & analysis of provide coding patterns
 Development of electronic audit tracking tools
 Development of action plans
 Operational actions, including:
 Internal/External audits
 Internal/External education
 Documentation improvement
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EDUCATION
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You are required to know the rules,
regardless of how many rules there are,
and how many exceptions there may be to the rules
If a provider understands and applies the rules correctly,
mistakes that result in costly audits are less likely to occur
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IMPORTANCE OF A COMPLIANCE PLAN
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 Sets the tone of your program
 Base it on reality – you have to live up to it
 Set standards
 Address risk areas
 Address corrective action plan
 Develop policies and procedures in support
 Developing a corresponding training program
 Develop lines of communication
HealthCare Management Consultants 2013
OIG: RECOMMENDED COMPONENTS
OF A SMALL PRACTICE COMPLIANCE PLAN
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1.
2.
3.
4.
5.
6.
7.
Internal Auditing & Monitoring Practice & Procedures
Establish Practice Standards & Procedures
Designation of a Compliance Officer/Primary Contact
Conducting Education & Training
Responding to Identified Issues & Corrective Action
Plans
Developing Open Lines of Communication
Enforcing Disciplinary Standards

See OIG Compliance Program for Individual and Small Group Physician Practices
October 5, 2000
HealthCare Management Consultants 2013
SAMPLE:
EXTERNAL AUDIT EXPERT ROLE
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 Identify different audit entities
 Know the audit scope, if any, for each entity
 Distinguish type of audits based on agency
 Know their time lines and procedures for response
 Develop communication forms
 Review all audit requests
 Manage and track responses
 Develop lines of communication with audit entities
 Communicate internally to facilitate change where
necessary
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING
AN
AUDIT
REQUEST
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 Audit requests are time-limited – do not let them sit in an
“in box” during any step in the process
 Policy should indicate a specific individual to receive the
request
 On Master Log, log in the request
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Name/MRN # of patient
Note and document the date of receipt
Note the date response is due
Date of service information is requested for
List of information requested
Document who is requesting the information
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING AN AUDIT REQUEST
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 Read and assess the request
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What exactly is the audit looking for
Determine the validity of the request
Understand why the request was made and if provider/staff behavior
triggered request
 Read and assess the chart notes
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If there is an allegation of error or wrong doing, does the documentation
refute it?
Does the documentation support the codes reported
Were modifiers appropriately applied
Is the note legible, properly authenticated and signed
Does the note reference previously documented information (i.e., “refer to
health history form”)
 Never send original documents
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING AN AUDIT REQUEST
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 Make two copies of all requested and referenced
information
 Page number everything being sent
 Based on the request, understand what to send and what
not to send
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If the chart note references another document like the Health
History form, copy and include it
Question: enclose test results or not?
 Don’t fabricate documentation if it isn’t there, it isn’t there
 Double check that everything being sent is for the
requested date of service
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING AN AUDIT REQUEST
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 Copy the request
 Review the copies for copy legibility

(i.e., copy isn’t too light, too dark, full page copied, appropriate orientation, etc)
 Don’t write directional notes on the copy
 Clip one copy of the copied records and the copy of the request
together (Set 1); request on top of records
 Clip the other set of copied records and the original request
together (Set 2); request on top of records (to be retained, so
you know exactly what was submitted)
 If the request includes multiple patients, there should be a set
for each individual patient. Highlight the patient name on each
set
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING AN AUDIT REQUEST
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 Prepare Set 1 for submission


Note any specific information about how the information is to be
received (mail, fax, etc.) and two whose attention it should be sent
Send as directed
 If there is no direction on how the packet is to be sent, options
are:
 Fax
 .pdf files
 Open mail
 Tracked mail
Preference is always tracked mail with a return receipt
requested; some groups also submit by fax – noting this is a fax
copy, with hard copy also on the way
HealthCare Management Consultants 2013
SAMPLE PROCEDURE:
RECEIPT & PROCESSING AN AUDIT REQUEST
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• On Master Log, log in date sent, to whom and method of
transmission
• File Set 2 as pending
• Track for claim adjudication/carrier response
• Facilitate provider/staff education, if request is generated by
need for education and/or change
HealthCare Management Consultants 2013
SUBMISSION TIMELINES
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MACs, RACs, CERT, & ZPICs
Pre-payment Review Time Frames
 Submit w/n 30 calendar days of request
 No extensions granted
 Claim denied if requested data not received by day 45
Post-payment Review Time Frames
 MAC, CERT, RAC: submit w/n 45 calendar days of request
 ZPIC: submit w/n 30 calendar days of request
 MAC, CERT, ZPIC have discretion to grant extensions
Refer to Medicare Program Integrity Manual, Chapter 3 for detailed guidelines on
submission, including timelines, submission methods and additional information
HealthCare Management Consultants 2013
WHAT AUDITORS MAY REQUEST
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At minimum. Auditors will require your chart notes for review.
They may also request other information, including:
 Referenced data not initially provided
 Appointment schedules
 Time stamp logs
 Chart notes for dates before and after the reviewed date
(looking for cloning)
 Diagnostic tests
HealthCare Management Consultants 2013
APPEALS PROCESS
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 Level 1:
 Level 2:
 Level 3:
 Level 4:
 Level 5:
Redetermination by a Medicare Contractor
Reconsideration by a Qualified Independent
Contractor (QIS)
Hearing Before an Administrative Law Judge
(ALJ)
Review by the Appeals Counsel
Judicial Review in Federal District Court

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For details and timelines for each level of appeal,
-see CMS MLN “The Medicare Appeals Process”
AUDIT TIPS
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 Treat every request seriously, even if it’s a request for a





single note for clarification of a service for claims
payment – it’s still an audit
Educate based on audit request findings
Pay attention to time lines for submission
Clarify & communicate “chain of command” for incoming
documents related to carrier communication
Private carriers may audit just as actively as Medicare
Know when to involve your health care attorney
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OTHER ACRONYMS USED IN THIS PRESENTATION
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ACRONYM
TRANSLATION
CMS
Center for Medicare & Medicaid Services
LCD
CMS Local Coverage Determinations
NCCI
National Correct Coding Initiatives
MUE
Medically Unlikely Edits
FFS
Fee for Service
CIA
Corporate Integrity Agreement
HHS
Health & Human Services
ADR
Additional Documentation Request
AC
Affiliated Contractor
RA
Remittance Advice
MLN
Medicare Learning Network
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RESOURCES & WEBSITES
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 Noridian Healthcare Solutions
https://www.noridianmedicare.com/
 Health Data Insights
http://www.healthdatainsights.com/
 OIG
http://www.oig.doc.gov/Pages/default.aspx
 Medicare Program Integrity Manual
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-OnlyManuals-IOMs-Items/CMS019033.html
 AHIMA
http://www.ahima.org/
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RESOURCES & WEBSITES
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 Federal Register (OIG Compliance Plan)
https://oig.hhs.gov/authorities/docs/physician.pdf
 Recovery Auditing Program for FY 2011
http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Recovery-Audit-Program/Downloads/FY2011-Report-To-Congress.pdf
 HEAT
http://www.stopmedicarefraud.gov/aboutfraud/heattaskforce/
 Senate Bill S.1012
http://www.govtrack.us/congress/bills/113/s1012#summary/libraryofcongress
 2012 CERT ERROR TYPES top 20
http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/CERT/Downloads/AppendicesMedicareFeeforService2012ImproperPayment
sReport.pdf
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RESOURCES & WEBSITES
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 CMS MLN: The Medicare Appeals Process
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/medicareappealsprocess.pdf
 CMS MLN: Medicare Claim Review Program
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/MCRP_Booklet.pdf
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Thank you for participating today!
Your presentation by:
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CAROL WINTERMUTE, ACS-EM
H E A LT H C A R E M A N A G E M E N T C O N S U LTA N T S
7 0 7 0 S W 1 6 9 TH
B E AV E R TO N , O R E G O N
97007
C O N TA C T U S :
PHONE: 503-591-7264
FA X : 5 0 3 - 8 4 8 - 4 6 6 4
W I N T E R M U T E M C @ C O M C A S T. N E T
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