Home Care Advocates Cite 15 Problems with Medicare Audits

Better oversight, established standards, and a higher level of accountability expected from organizations could reduce fraud and abuse in the Medicare audit system according to recommendations made by independent providers in the health care industry. 

A white paper written in response to the U.S. Senate Committee on Finance’s request for comments to aid in fraud reduction in the Medicare system was published earlier this month and offers recommendations from independent providers including VGM Group, a national buying group for independent home medicare equipment providers.

VGM cites the four main problems present in Medicare auditing as lack of oversight, lack of regulations and standardization, lack of transparency, and lack of accountability and enforcement. 

Outlined in the white paper are 15 specific problem areas and the industry’s recommendations for addressing them. Most of the 15 problem areas involve Zones Program Integrity Contractors (ZPICs), Medicare Administrative Contractors (MACs), and Durable Medical Equipment (DME) Suppliers.

Documentation is at the center of many specific problems addressed in the paper. Providing correct documentation for DME suppliers and relieving them of penalties incurred due to improper documentation filed by other professionals are two recommendations found in the letter.

Holding ZPICs and MACs more accountable by enforcing deadlines in responding to redetermining and reconsidering Medicare claim decisions. 

In a move to improve communication and reduce confusion and fraud, VGM suggests more concise requirements be given to providers when establishing medical necessity and more concrete standards established for the “continued medical need” and “ongoing use” of rental DME items. 

The paper also cites unnecessary conflict caused by the Competitive Bidding Program and ZPIC auditing processes as an issue and recommends the integration of the audit process and the bidding program. 

Read the white paper here.

Written by Erin Hegarty

Erin Hegarty