I’ve been reading various websites that purport to give advice about defending against overpayment extrapolations done by various CMS contractors or the OIG. It doesn’t seem like many of them have any actual insider knowledge about how extrapolations are done or what might be helpful during the audit or during the appeals process.
In fifteen years of working with Medicare, I have never had the impression that any CMS contractor is “out to get” providers. On the contrary, I have seen repeated efforts to “bend over backwards” to help providers get into compliance with the Medicare program, sometimes working for years with extremely recalcitrant providers trying to get them to bill properly and stop abusing the Medicare payment system. Thus my first piece of Honest Advice is this: When Medicare tells you that you are doing something wrong, or may be doing something wrong and should internally investigate, LISTEN! This is your first opportunity to head off any possible extrapolation! If you have questions, or are unsure what the issue might be, work with the contractor (or your MAC) to understand the issue. Get medical review experts to advise you on proper billing and documentation.
I know documentation requirements are onerous. This is the government we’re talking about. I know medical professionals are chafing under the documentation load already. I know documentation requirements are raising the cost of medical care and not necessarily improving the quality. These are my opinions, which I think are widely shared in the industry. HOWEVER, you cannot escape the fact that Medicare payment is contingent on proper documentation. If you don’t have the documentation that is required, it is essentially illegal for you to accept payment, and it is an error for the MAC to give you payment (even when no documentation was requested). Time and time again I have seen the argument made that the government did not prove the service was not rendered, nor that it was not necessary. But this is irrelevant–if you did not prove the service was rendered, medically necessary, and covered by Medicare in your documentation, you are not entitled to payment from Medicare. It’s really that simple. In addition, if you knowingly accepted payment in the absence of proper documentation, you are getting into the realm of actual fraud, regardless of whether the actual services were proper and payable in every other way.
Many providers attempt to appeal an extrapolation by challenging the statistics. There are several (questionable) experts out there who make it their business to try to get extrapolations overturned with a variety of spurious arguments. This used to work sometimes, because ALJs where not properly educated about the statistical aspects of these appeals, and, particularly if the contractor did not attend the hearing, they were duped into believing these claims. Things have gotten much tighter now. There are a number of Departmental Appeals Board decisions and Circuit Court decisions that back up and provide legal precedent for extrapolation methods. It is true that mistakes occasionally occur in the extrapolation process, and providers should not neglect to examine the methodology closely. However, they should not rely on this, and should be prepared to accept the decision of a consultant (one with actual Medicare extrapolation experience) that the extrapolation was conducted properly.