If you’re a physician, doctor or other healthcare provider of any kind and you receive a records request letter from Medicare or a Zone Program Integrity Contractor (ZPIC) that expresses interest in auditing your practice or healthcare business you should immediately consult with experienced health law counsel. It is imperative to retain an attorney immediately upon receiving a Medicare records request letter asking for medical records or a set number of claims. Attempting to respond to a notice like this is fraught with many pitfalls a provider can fall into, potentially making the Medicare audit scenario worse for themselves. Providers and suppliers need to understand the process and more importantly, how to navigate that process effectively and with as little business interruption as possible.
In today’s heightened regulatory environment, providers and healthcare businesses need to take all types of communication from managed care and governmental payors seriously. There is increased spending and enforcement in the governmental sector to go after fraud and abuse. Failure to respond timely or properly to a Medicare records request letter can have devastating consequences. For non response, providers may have their billing privileges taken away or deactivated, Medicare could swiftly take back the overpayment amount or worse, freezing business altogether.
When a provider receives a Medicare review results letter they should be looking at something that helps them understand Medicare’s statistical methodology and it should tell the provider both what the overpayment amount is and how they (Medicare) got to that number. The review results letter will tend to get specific, showing a provider within the sample information including which claim they covered, denied or downcoded. At that point, appeal rights haven’t started and providers don’t owe anything yet but they do need to understand what the Medicare review results letter is saying. If a provider hasn’t engaged experienced counsel by the time they arrive at the Medicare review results letter, the time is now. It is wise at this point for providers to not only have a healthcare lawyer working alongside them, but to consider engaging their own expert in preparation for challenging this determination. Providers facing Medicare audits will go through multiple steps but engaging proper counsel is imperative because by step two or three they can get hung up for years waiting for auditors to cycle through backlogs of similar cases. Years of waiting for a Medicare appeal is enough to cripple or even shut down a sound healthcare business. Going at it alone after receiving a Medicare review results letter is not a sound strategy.