Eli's Hospice Insider

Published on Thu Mar 15, 2018 PDF

A Medicare contractor audit that uses statistical sampling can strike fear into providers' hearts, as damaging - often door-closing - overpayments may be assessed based on a small number of claim reviews.

The HHS Office of inspector General is tackling the topic of statistical sampling in a newly announced Work Plan topic. "Medicare program integrity contractors are authorized to use statistical sampling to identify and recover improper payments.

Providers may contest these statistical estimates through the administrative appeals process," the OIG says on its website. "If a statistical estimate is overturned during the administrative appeals process, then the provider is liable for any overpayment upheld in the sample rather than the full, extrapolated total. The difference between these amounts is often substantial."

Focus: "The Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) are responsible for the first two levels of the appeals process and thus play a critical role in deciding which extrapolations will be upheld," the OIG notes. "We will determine whether the MACs and QICs are reviewing statistical estimates in an appropriate and consistent manner as part of the fee-for-service appeal process."

The OIG expects to issue the report next year, it says at https://oig.hhs.gov/reports-and-publications/workplan/summary/wp-summary-0000274.asp.