Physicians being reviewed or audited by Medicare may want to take the following items into consideration:
- Physicians selected for medical review are done so after consideration of the presenting problem, data analysis, peer comparison, and/or receipt of reported information on possible fraud and abuse to the program. The majority of prepayment reviews result from a comprehensive data analysis that demonstrates irregular or inappropriate billing.
- Medicare will send an official certified letter notifying a physician when and why the physician is being placed on review. The letter will give all the pertinent information. The physician should read the letter very carefully and follow all instructions for submitting claims and medical records.
- TMA recommends that the physician, after being placed on review by Medicare, request a meeting with the Medicare medical director and the Medicare Integrity Program (MIP) provider education specialist who is assigned to the case. The MIP provider education specialist usually is the physician's contact person for any questions regarding prepayment review. This meeting will allow the physician to ask questions regarding the review and to obtain a better understanding of the situation and medical review process.
- The physician may want to consider having an attorney attend the meeting as well. Any physician needing contact information for a health care attorney may contact the TMA Office of General Council at (800) 880-1300, ext. 1341, or (512) 370-1341; however, TMA itself does not get involved in matters of this nature.
- Keep in mind that the medical records must speak for themselves. The records must appropriately document all services and clearly support the medical necessity of the services. Do not attempt to alter any medical records.
- Be sure to refer to the Medicare Documentation Guidelines for Evaluation and Management Services for proper documenting of services.
- For specific items or services being questioned in a review, locate the complete Medicare policy for those items or services. Medicare Part B newsletters clearly explain billing and coverage policies.
- Physicians may want to initiate an outside audit of their own medical records for an unbiased opinion of proper documentation and coding of the services billed to Medicare. Reputable health care consultants, such as TMA Physician Services , should perform such an audit.
- Medicare encourages self-disclosure of any identified billing errors. True billing errors are not considered "fraud" under the Medicare definition.
- Should Medicare find the physician's documentation and billing patterns are correct, the medical review process should be short-lived.
- Should Medicare find billing errors and insufficient documentation, the review process may be lengthy.
- TMA recommends that the physician be willing to accept and implement necessary changes in billing patterns and/or documentation habits if needed.
- The physician maintains full appeal rights on all claims audited by Medicare.
Notice: The TMA Office of General Counsel provides this information with the express understanding that (1) no attorney-client relationship exists, (2) neither TMA nor its attorneys are engaged in providing legal advice, and (3) the information is of a general character. You should not rely on this information when dealing with personal legal matters; rather, seek legal advice from retained legal counsel. (January 2002)
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