Medicare and the Game of “Gotcha”

January 25, 2022
Medicare & Medicaid

I am a devoted follower of Knicole Emanuel’s legal blog, which focuses on Medicare and Medicaid. She manages to make complex (and sometimes boring) topics both understandable and interesting. What she can’t do is make the news good instead of bad. It’s a well-known fact that the Medicare trust fund is bankrupt. What’s keeping Medicare afloat are “recoupments” – that is, taking back money already paid to doctors and hospitals.

In her blog, Ms. Emanuel provides an overview of the audit performance of 900 healthcare facilities, and correctly observes that audit data are like blood in the water for sharks. Knowing that there are “issues” in terms of the billing integrity, the RACs, MACs, UPICs, and all other alphabet soup of auditors will have a feeding frenzy.

It’s true that there is a Medicare fraud problem out there (most of us have seen it), but I haven’t seen the real fraudsters get hit with paybacks – all I have seen are the reputable folks getting caught up in a game of “Gotcha” with the various Medicare contractors, sometimes focused on whether specific words are in the chart. For example, some payments for hyperbaric oxygen therapy were recouped because the treatment note did not specify that the patient was treated in a “hard-sided chamber.” I can quote a lot of examples like this.

In my Medicare region, there are 24 different items that have to be documented in the note for a “skin substitute” (cellular and/or tissue-based product – CTP). I won’t bore you with the list except to say that it’s long and detailed and when they audit those procedures, they may be looking to see if the diabetic foot ulcer has been off-loaded at every visit or the venous leg ulcer treated with compression at each visit for the preceding month, and not just whether there’s a detailed note on the application of the product. Hospitals and practitioners have to be constantly updating their procedure note templates – or hoping that their EHR vendor is doing it for them. In this game, you may find out the rules only when someone gets a penalty.  The rule book keeps changing as we are playing.

Caroline Fife, MD

Dr. Fife is a practicing wound care physician, Director of the Wound Care Center at CHI St. Luke’s The Woodlands Hospital, Co-Founder and Chief Medical Officer of Intellicure, Executive Director of the US Wound Registry, and Editor of Today’s Wound Clinic.

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