Should your clinic or practice be subjected to a government contractor review or audit by either a Recovery Audit Contractor or a Program Safeguard Contractor, it is imperative that you fully understand how the appeal process works so that you can properly assert any and all arguments and defenses in support of payment.  Providers have a right not merely to contest but also to know the specific basis on which a denial has been based – not merely the substantive reason for denying the claim (e.g. medical necessity), but also the statute, regulation and / or policy upon which the denial was based.  Liles Parker has years of experience assessing these denials and asserting reasons why the provider’s claims are properly payable. Learn More

Congress has taken a number of actions in an effort to address Medicare fraud and reduce the extent of improper claims being paid each year.  The Medicare Integrity Program (MIP) was established as part of HIPAA in 1996 to strengthen CMS’ ability to reduce fraud and abuse in the Medicare program.  In 1999, CMS began transferring the responsibility for detecting and deterring Medicare Part A and Part B fraud and abuse to PSCs.  In 2006, CMS completed the transfer of fraud and abuse work from the Carrier and Intermediary fraud units to the PSCs.  In late 2008, CMS again changed the program, transferring the responsibility for conducting PSC-type medical review duties to Zone Program Integrity Contractors (ZPICs).  There are currently twelve PSCs that have been awarded umbrella contracts from CMS, but at the end of these contracts, fraud detection and deterrence functions will be transferred to ZPICs.  Learn More

Despite the successes achieved by PSCs, Congress believed that additional measures to safeguard the Medicare Trust Funds were needed.  As part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), Congress directed CMS to conduct a three year pilot project examining the use of Recovery Audit Contractors (RACs) to detect and correct improper payments. Satisfied with the results of the program, Congress passed the Tax Relief and Health Care Act of 2006 to make the RAC program permanent. RACs were not intended to replace other claims review efforts by MACs, PSCs, Benefit Integrity Support Centers or HHS-OIG Learn More