Like all insurance providers, the Centers for Medicare and Medicaid Services (CMS) conduct thousands of routine audits to ensure that they are reimbursing only those services which are appropriate and medically necessary. Every year, countless practices are examined, and many of them yield surprising results regarding miscoded procedures. Sometimes these errors are simple mistakes; sometimes they are intentional scams. Either way, CMS is known for meting out harsh punishments for those who receive improper reimbursement. But can they sometimes go too far?
Recently, a Tennessee physician lost his Medicare billing privileges for a full three years due to 30 errors over a 20-month period. To put that into perspective, the audits reviewed over 30,000 claims from the practice and found only these 30 issues, making the provider’s error rate less than one-tenth of a percent. Worse still, the physician appealed the decision by saying that all errors were due to simple mistakes (such as two patients having the same name) rather than an intentional attempt to defraud, but the appeal was overturned.
On CMS’s, side of the story, however, they argue that harsh measures are necessary because of the number of practices who otherwise wouldn’t take such investigations seriously. The organization already raised its civil monetary penalties back in 2015, claiming that many practices were not making the changes they had been ordered to make in the past. Though their frustration with non-compliant practices is understandable, cracking down to the point of hurting those with infinitesimal problem rates seems nearly as bad as letting abuse run rampant.
With any luck, these issues will be sorted out over time. The more practices that can focus on internal audits and fix issues before they are found by CMS, the more likely that these intense penalties will be abandoned in favor of a more reasonable approach in the future.