Providers stress over looming Medicare prepayment audits

Even though the Centers for Medicare & Medicaid Services (CMS) has delayed them, hospitals and physicians still are worried about looming prepayment reviews of Medicare claims in a governmental crackdown on improper payments and errors.

CMS last month published national plans to increase the number of reviews to 2.7 million claims a year, up from 1.2 million claims, according to American Medical News. Some providers voiced concerns about the audits, including the American Medical Association, which stated, "The AMA agrees that this is an important goal, but we do not accept that broad-brush prepayment review is the best or only way to achieve that goal," wrote AMA Executive Vice President and CEO James L. Madara in a letter to CMS, amednews reported.

Providers also have expressed concerns about lost reimbursements that the Medicare prepayment reviews could cost them.

For example, in Florida, Medicare contractor First Coast Service Options has targeted 11 cardiology and four orthopedic surgeries for prepayment review. Calling it an unprecedented scope of the prepayment policy, physicians are worried the policy would apply to 100 percent of claims for certain services that would be subject to review. First Coast clarified that only 30 percent of claims for 14 of the listed procedures would be subject to prepayment review, and the contractor would review 50 percent of claims for major joint replacements or reattachments, according to the article.

After receiving comments about the prepayment audits that had been scheduled to start this month, CMS delayed the prepayment audits. The agency said it will provide at least 30 days' notice before implementing the prepayment audits throughout 11 high-fraud states: Florida, California, Michigan, Texas, New York, Louisiana, Illinois, Pennsylvania, Ohio, North Carolina and Montana.

For more information:
- read the amednews article

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