Tampa Medicare Audit Defense for Healthcare Providers
A Medicare audit asks the same question of every chart: does the record prove the service was covered, ordered and necessary? The answer rarely depends on how good the care was. It depends on whether a specific form, signature or certification is where the rules require it. If your practice or agency in Tampa Bay is under review, you need Tampa Medicare audit defense that starts with the record, not the argument.
The Health Law Offices of Anthony C. Vitale, now practicing as Vitale, Suarez & Associates, P.A., is a Florida healthcare law firm founded in 1982. Its office is in Miami Lakes, and it represents providers throughout Florida, including the Tampa Bay area, in Medicare audits.
What Auditors Look For, by Provider Type
- Home health agencies. The face-to-face encounter, the certification of homebound status and the plan of care.
- Hospices. The certification of terminal illness and documentation that supports the prognosis throughout each benefit period.
- DME suppliers. A valid order, documentation of medical necessity and proof of delivery.
- Clinical laboratories. An order from the treating practitioner and evidence that the test was used in the patient's care.
- Therapy providers. A plan of care certified by the physician or qualified practitioner on time.
- Physician practices. Evaluation and management levels supported by the note, and incident-to requirements met.
Undocumented care is treated as care that never happened. The auditor reads what is in the file, not what the team remembers.
Targeted Probe and Educate and Prepayment Review
Under Targeted Probe and Educate, the Medicare Administrative Contractor reviews a set of claims in up to three rounds, with education between rounds. It looks like a conversation. It is also a record: continued errors can lead to prepayment review, an extrapolated overpayment or a referral. Under prepayment review, every claim in the target group waits for a documentation review before it is paid. That is a cash flow problem before it is a legal one, and it needs both kinds of plan.
When an Audit Reaches Your Enrollment
Audit findings can follow a provider into enrollment. Under 42 C.F.R. § 424.535, CMS can revoke Medicare billing privileges on grounds that include noncompliance with enrollment requirements and a pattern of claims that do not meet Medicare requirements. A revocation ends billing privileges and is usually followed by a bar on re-enrolling for a period of years. A deactivation is different: it stops billing privileges, for example after a failed revalidation, but can usually be reversed once the problem is corrected.
Every revocation notice states its own deadlines for a corrective action plan or a reconsideration request. Read them the day the notice arrives.
Strategic Legal Solutions for Healthcare Providers
Building the Response
- Audit the charts yourself, with counsel, before the contractor does
- Identify what is missing and what is only hard to find
- Use only corrections the rules allow. A signature can sometimes be supported by an attestation that meets CMS requirements. A missing order or certification cannot be created after the fact, and no document should be.
- Keep the response to what the records support
The firm’s in-house IT and forensic investigations team can review EHR audit logs and metadata, so that the dates in the record can be defended before an auditor questions them.
Frequently Asked Questions
Can a TPE review lead to a larger audit?
Yes. If errors continue after the TPE rounds, the contractor can refer the provider for further action, including prepayment review or a post-payment review that uses extrapolation.
What is the difference between deactivation and revocation?
A deactivation stops billing privileges, often for a correctable reason such as a missed revalidation. A revocation ends them and is usually followed by a re-enrollment bar.
Do I have to respond to a prepayment review request?
Yes. Claims without the requested documentation are usually denied, and those denials feed the error rate.
Does the firm have an office in Tampa?
The firm’s office is in Miami Lakes. It represents healthcare providers throughout Florida, including the Tampa Bay area.
The owner of a Tampa, Florida-area medical marketing company was sentenced to 70 months in prison today for his role in a $2.2 million Medicare fraud scheme involving the payment of kickbacks and bribes to fraudulent medical clinics in Miami in exchange for the referral of Medicare beneficiaries for expensive genetic tests that were medically unnecessary, and for his role in the illegal structuring of cash withdrawal transactions.
Assistant Attorney General Brian A. Benczkowski of the Justice Department’s Criminal Division, U.S. Attorney Maria Chapa Lopez of the Middle District of Florida, Special Agent in Charge Michael McPherson of the FBI’s Tampa Field Office and Assistant Inspector General Omar Perez of the U.S. Department of Health and Human Services Office of the Inspector General’s (HHS-OIG) Miami Regional Office made the announcement.