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What Anesthesiologists Need To Know About Medicaid’s Contracted Auditors

WHAT ANESTHESIOLOGISTS NEED TO KNOW ABOUT MEDICAID'S CONTRACTED AUDITORS

November 30, 2009

Although there has been a lot of discussion on the Medicare Recovery Audit Contractor (“RAC”) program, little attention has been paid to the first national Medicaid audit program resulting from the creation of the Medicaid Integrity Program (“MIP”). As part of the MIP, the government has entered into contracts and awarded task orders to various vendors called Medicaid Integrity Contractors (“MICs”). Auditing activity under the MIP began in September of 2008 and according to the last formal published statistics in July of 2009, was underway in approximately 20 states, with initial estimates to be in every state by late 2009. Unlike the Medicare RAC program, the MICs are not paid on a contingency fee basis and the overpayment and appeals process will be handled based on the applicable state specific process. Moreover, this Medicaid audit program does not contain limitations with regard to the time periods that may be reviewed and does not have built in record request limitations.

The MICs can undertake desk audits or field audits and have the authority to interview personnel in addition to requesting and reviewing actual records. If your practice is selected for audit, you will receive an audit notice letter requesting designated records within a designated timeframe. The notice letter should also contain a contact person at the MIC and you should also expect to receive information about the scheduling of an entrance conference. Once the audit is complete, you should also expect to receive a preliminary audit report in which you will be given a time frame to provide additional information and make comments. At the conclusion of this process, you should expect to receive a final report and will be able to appeal the findings through the existing state appeals process.

Unfortunately, the MIC audits will be yet another layer of auditing that you could face in the years ahead; underscoring the importance of undertaking compliance activities, including improving or enhancing documentation protocols. As this is the first national Medicaid audit program, there is no historical data to draw on regarding any particular focus areas for anesthesiologists and pain management physicians. However, we recommend that groups take the time to strengthen their compliance programs to oversee that certain traditional anesthesia and pain management focus areas are enhanced. For example, among other areas, we encourage your practice to:

  1. ensure that each provider is only capturing allowable anesthesia time and that appropriate documentation exists to support the recorded start and end times;
  2. ensure compliance with the medical direction requirements including increasing documentation practices to demonstrate such compliance;
  3. review documentation practices with regard to separately payable services such as invasive monitoring lines and post-operative pain services;
  4. review medical necessity and overall documentation in connection with the provision of chronic pain management procedures; and
  5. carefully evaluate medical necessity and utilization with regard to pain management services.

With best wishes,

Tony Mira
President & CEO