Medicare Audit

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buddababa

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Anyone ever had this happen to them?

Medicare is conducting a 20 case review of your facet joint injections, please reviewed the LCD....."

What to expect?
 
not good. likely will be on pre-payment review for 1-2 years.
 
My group has had a couple providers have "educational" audits from the LCD people. They're pretty crap because they seem to make up their own rules you "should be following", even if this rule isn't written down. Not sure how much that helps you though.
 
So I got a request for a Medicare RAC audit done by Noridian for 40 Lumbar MBB's done in 2019.
They are claiming that you have to wait for 3 months for any facet intervention. They seem to have an issue with waiting 1 week and repeating an MBB. Palmetto GBA which was out MAC contractor then did not have anything like this in their LCD. Noridian is performing the Audit.

Also WTF, wait for 3 months to repeat an MBB ?
I have requested an extension to resubmit the documents.

Any and all help is appreciated including possible lawyers / Auditors who can help.

Should I be worried ?

Thanks.
 
bronchospasm said:
So I got a request for a Medicare RAC audit done by Noridian for 40 Lumbar MBB's done in 2019.
They are claiming that you have to wait for 3 months for any facet intervention. They seem to have an issue with waiting 1 week and repeating an MBB. Palmetto GBA which was out MAC contractor then did not have anything like this in their LCD. Noridian is performing the Audit.

Also WTF, wait for 3 months to repeat an MBB ?
I have requested an extension to resubmit the documents.

Any and all help is appreciated including possible lawyers / Auditors who can help.

Should I be worried ?

Thanks.
Click to expand...
3 mo of pain, and I think conservative tx, before MBB1, not between MBBs. 2 weeks between MBBs is a new change, wasn't applicable in 2019.
 
They say 1 week between MBB1 and MBB2 is too soon. In 2019, LCD said that MBBS should be done on separate days, thats it.
 
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Completely garbage.

I would definitely have an attorney help you with this rebuttal.

40 potential MBB clawbacks that could lead to RFA clawbacks is not a small chunk of change...
 
1651886987014.jpeg
 
There were several good speakers/panelists at the ASIPP occurring this week who talked about audits and defending yourself during it. You may wanna reach out to those speakers.
 
bronchospasm said:
So I got a request for a Medicare RAC audit done by Noridian for 40 Lumbar MBB's done in 2019.
They are claiming that you have to wait for 3 months for any facet intervention. They seem to have an issue with waiting 1 week and repeating an MBB. Palmetto GBA which was out MAC contractor then did not have anything like this in their LCD. Noridian is performing the Audit.

Also WTF, wait for 3 months to repeat an MBB ?
I have requested an extension to resubmit the documents.

Any and all help is appreciated including possible lawyers / Auditors who can help.

Should I be worried ?

Thanks.
Click to expand...

These requests are common, Medicare has been asking practices all across the country for MBB notes. Standard ask is for 20 charts per provider. They’ve hit us twice now. First time they recouped money on 19 out of 20. They nitpicked everything single note and basically noted any reason they could to take money back. Second time they didn’t fare so well because we obviously made changes to all of our templates to include everything they got us for the first time around. And to think we thought we were documenting well to begin with haha. 19 out of 20 was really bad failure rate! Probably would have had some success fighting them but figured we’d just pay them the money and move on, not poke the bear.
 
gdub25 said:
These requests are common, Medicare has been asking practices all across the country for MBB notes. Standard ask is for 20 charts per provider. They’ve hit us twice now. First time they recouped money on 19 out of 20. They nitpicked everything single note and basically noted any reason they could to take money back. Second time they didn’t fare so well because we obviously made changes to all of our templates to include everything they got us for the first time around. And to think we thought we were documenting well to begin with haha. 19 out of 20 was really bad failure rate! Probably would have had some success fighting them but figured we’d just pay them the money and move on, not poke the bear.
Click to expand...
what were the things they penalized you guys for the first time around?
 
All chart requests were from 2019. There were lots of different things they got us for. Not documenting specifically “pain with facet loading” was one. Another that I remember was that in the note it said pain radiates down the posterior thighs but Medicares policy states the pain “must not radiate down the extremity” or something like that. They had one that they said the patient needed 80% relief with the first block to proceed with second but we reported 70% (back then in 2019 our LCD only requires 50%, should have argued this one). We had one that we used steroid in but the note template says “diagnostic facet injection” and they deemed it wrong stating diagnostic can’t have steroid. There really didn’t seem to be any recurring theme, just lots of little things. For us, the clear take away message was that medical notes and billing are something we just have to treat as a game of cat and mouse. Make the notes templates say exactly what insurance requires and then at the bottom we personally type what we need for ourselves for providing quality medical care.
 
gdub25 said:
All chart requests were from 2019. There were lots of different things they got us for. Not documenting specifically “pain with facet loading” was one. Another that I remember was that in the note it said pain radiates down the posterior thighs but Medicares policy states the pain “must not radiate down the extremity” or something like that. They had one that they said the patient needed 80% relief with the first block to proceed with second but we reported 70% (back then in 2019 our LCD only requires 50%, should have argued this one). We had one that we used steroid in but the note template says “diagnostic facet injection” and they deemed it wrong stating diagnostic can’t have steroid. There really didn’t seem to be any recurring theme, just lots of little things. For us, the clear take away message was that medical notes and billing are something we just have to treat as a game of cat and mouse. Make the notes templates say exactly what insurance requires and then at the bottom we personally type what we need for ourselves for providing quality medical care.
Click to expand...
thank you for this.

i hate how we have to exclusively separate facet pathology with any radicular/stenotic pathology. degeneration of spine is a continuum and patients can easily have both. so frustrating.
 
gdub25 said:
All chart requests were from 2019. There were lots of different things they got us for. Not documenting specifically “pain with facet loading” was one. Another that I remember was that in the note it said pain radiates down the posterior thighs but Medicares policy states the pain “must not radiate down the extremity” or something like that. They had one that they said the patient needed 80% relief with the first block to proceed with second but we reported 70% (back then in 2019 our LCD only requires 50%, should have argued this one). We had one that we used steroid in but the note template says “diagnostic facet injection” and they deemed it wrong stating diagnostic can’t have steroid. There really didn’t seem to be any recurring theme, just lots of little things. For us, the clear take away message was that medical notes and billing are something we just have to treat as a game of cat and mouse. Make the notes templates say exactly what insurance requires and then at the bottom we personally type what we need for ourselves for providing quality medical care.
Click to expand...
That’s incredibly frustrating and I hope this doesn’t happen to you again. Are u private or hospital affiliated? I feel like hospitals would have their own ways to prevent these issues. We should create a website that has these tried and tested templates , or we can share them here
 
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Argument with Evicore two yrs ago regarding facet pain in the buttocks and hamstrings, which is both well-described in the literature and repeatedly proven as factual to me on a day to day basis. I have a tremendous amount of Medicare pts with low back, buttock and hamstring pain that responds very well with L4-S1 RFA.

"You sir have no business being on the other end of this phone call with me."

- Me to the Evicore guy
 
MitchLevi said:
Argument with Evicore two yrs ago regarding facet pain in the buttocks and hamstrings, which is both well-described in the literature and repeatedly proven as factual to me on a day to day basis. I have a tremendous amount of Medicare pts with low back, buttock and hamstring pain that responds very well with L4-S1 RFA.

"You sir have no business being on the other end of this phone call with me."

- Me to the Evicore guy
Click to expand...
You are correct. And all of our notes should reflect this. "referred pain" is not radicular pain. Tell Evicore to deny cardiac care for every MI that has jaw pain and left arm pain.
 
lobelsteve said:
You are correct. And all of our notes should reflect this. "referred pain" is not radicular pain. Tell Evicore to deny cardiac care for every MI that has jaw pain and left arm pain.
Click to expand...

Should undergo diagnostic SNRB first to rule out radiculopathy.
 
I’m getting the same thing right now. Out of 20, 10 are deficient. 5 for signatures which makes no sense. We’re having them reviewed now. All my notes are pretty similar so can’t wait to see what they invented.
 
I too am getting audited….

Can someone give insight in how to reach the people at ASIPP for insight? (Ie the ones who spoke)
 
Screenshots from my audit….4th from bottom doesn’t even have correct codes. Most of the denials are trying to claw back one level. 5 are for missing a signature, which can’t be right.
81375F4B-D6CB-4645-BBA4-39CEA80A7282.jpeg
AC1EBEE4-97A7-4477-B9C1-CFBB4A48833B.jpeg
F2029125-5928-468D-AE40-8891675C6432.jpeg
 
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painfree23 said:
That’s incredibly frustrating and I hope this doesn’t happen to you again. Are u private or hospital affiliated? I feel like hospitals would have their own ways to prevent these issues. We should create a website that has these tried and tested templates , or we can share them here
Click to expand...

We’re private.

All of our notes are templates and we have our billers/coders update the templates as they see changes and they tell us via group email what the guidelines are.

Also, get ready, SCS audits are next. Just got ours yesterday and talked to a couple of other docs who got the same request. Wanting charts from 2020.
 
MitchLevi said:
What's the price tag?
Click to expand...
they dont give you a number....we have a call set up soon.

We did a call today on LSO's from 2019. They said L0637 was custom fit, and we should have coded L0650 for off the shelf(OTS). We didnt document any custom fit or modifications to the LSO because we were told OTS was L0637 in 2019 and it was recently changed to L0650. Asking our DME company now because they basically made our templates.
 
“Also, get ready, SCS audits are next. Just got ours yesterday and talked to a couple of other docs who got the same request. Wanting charts from 2020.”

Good, not good that you are getting audited, but scs is over done and the KOLs need to return their pointy shoes asap
 
My ASC had a couple of Medicare audits on stimulators and needed my notes a few years ago. Oddly Medicare never reached out to me with the same concern. As far as I know we passed.
 
Doctodd said:
they dont give you a number....we have a call set up soon.

We did a call today on LSO's from 2019. They said L0637 was custom fit, and we should have coded L0650 for off the shelf(OTS). We didnt document any custom fit or modifications to the LSO because we were told OTS was L0637 in 2019 and it was recently changed to L0650. Asking our DME company now because they basically made our templates.
Click to expand...
L0637 should be measured, cut, heat gunned and molded, etc. That's why the reimbursement was so high.
 
gdub25 said:
We’re private.

All of our notes are templates and we have our billers/coders update the templates as they see changes and they tell us via group email what the guidelines are.

Also, get ready, SCS audits are next. Just got ours yesterday and talked to a couple of other docs who got the same request. Wanting charts from 2020.
Click to expand...

This is some high level private practice mojo you got going on here baby
 
So are you guys still getting paid ny medicare for all the billing during the audit? Or is money held
 
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ateria radicularis magna said:
This is some high level private practice mojo you got going on here baby
Click to expand...

Not sure what you mean. LCDs change regularly, insurances update medical necessity, etc. Billing team has to be on top of that, update the doctors, let us know what’s covered and make sure we know what the requirements are. Templates just save us time. No sense in us writing verbatim in every note “patient has positive facet loading pain” or “patient reported greater than 80% relief with diagnostic blocks” etc. I type LMBB if patient meets requirements for blocks, the template is inserted.

buddababa said:
Money is held.
Click to expand...

This hasn’t been our experience. We still got paid by Medicare when they were reviewing our 20 charts.
 
10KHertz said:
Medicare CMS is a bunch of cu..Ts…

Trying to retract one rfa after 3 years later for being 1 day over 6 months … Al Beit some
Months are 28 days… 😆

Pathetic auditors trying to make a living .

One in a thousand retraction .

If you newbies don’t fight , we are all screwed…
Click to expand...
forgot the n
 
gdub25 said:
Not sure what you mean. LCDs change regularly, insurances update medical necessity, etc. Billing team has to be on top of that, update the doctors, let us know what’s covered and make sure we know what the requirements are. Templates just save us time. No sense in us writing verbatim in every note “patient has positive facet loading pain” or “patient reported greater than 80% relief with diagnostic blocks” etc. I type LMBB if patient meets requirements for blocks, the template is inserted.



This hasn’t been our experience. We still got paid by Medicare when they were reviewing our 20 charts.
Click to expand...

I mean it sounds like you have a well run practice. Kudos.
 
Just got my 18 patient rfa audit from 2019-2020 . OIG doesn’t specifically state what the clinical issues were. My guess is that their system flags rfa close to 6 months esp, If you perform unilateral RAfa. They flagged a thoracic and cervical rfa within 6 months , probably don’t understand the overlapping codes .

My advice is the fight everything . Tell them they are unethical scum , and are abusing their auditing power . Strike some fear in this OIG dept.

ASIPP needs to grow a pair and fight for us, or give me back my diplomat status money, LAX…
 
10KHertz said:
Just got my 18 patient rfa audit from 2019-2020 . OIG doesn’t specifically state what the clinical issues were. My guess is that their system flags rfa close to 6 months esp, If you perform unilateral RAfa. They flagged a thoracic and cervical rfa within 6 months , probably don’t understand the overlapping codes .

My advice is the fight everything . Tell them they are unethical scum , and are abusing their auditing power . Strike some fear in this OIG dept.

ASIPP needs to grow a pair and fight for us, or give me back my diplomat status money, LAX…
Click to expand...
i am sure that the bureaucrats are quaking in their boots when 10khertz calls them unethical.....
 
My practice manager just called me (small practice), CMS has taken back 11K so far on RFA across 3 different providers (mostly me) from 2019/2020.

Letters have come for some of them stating "upon review, you were over paid" and the reason given is effectively "due to LCD".

No specific reason given.

Ay dios mio
 
xvaderx said:
My practice manager just called me (small practice), CMS has taken back 11K so far on RFA across 3 different providers (mostly me) from 2019/2020.

Letters have come for some of them stating "upon review, you were over paid" and the reason given is effectively "due to LCD".

No specific reason given.

Ay dios mio
Click to expand...

That’s insane.
 
xvaderx said:
My practice manager just called me (small practice), CMS has taken back 11K so far on RFA across 3 different providers (mostly me) from 2019/2020.

Letters have come for some of them stating "upon review, you were over paid" and the reason given is effectively "due to LCD".

No specific reason given.

Ay dios mio
Click to expand...
That's crazy. Where are the professional organizations fighting this?
 
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