Can Medicare/caid Auditors Double-Dip?

The issue today is whether health care auditors can double-dip. In other words, if a provider has two concurrent audits, can the audits overlap? Can two audits scrutinize one date of service (“DOS”) for the same consumer. It certainly doesn’t seem fair. Five years ago, CMS first compiled a list of services that the newly implemented RAC program was to audit. It’s been 5 years with the RAC program. What is it about the RAC program that stands out from the other auditor abbreviations?

We’re talking about Cotiviti and Performant Recovery; you know the players. The Recovery Audit Program’s mission is to reduce Medicare improper payments through the efficient detection and collection of overpayments, the identification of underpayments and the implementation of actions that will prevent future improper payments.

RACs review claims on a post-payment basis. The RACs detect and correct past improper payments so that CMS and Carriers, and MACs can implement actions that will prevent future improper payments.

RACs are also held to different regulations than the other audit abbreviations. 42 CFR Subpart F dictates the Medicaid RACs. Whereas the Medicare program is run by 42 CFR Subchapter B.

The auditors themselves are usually certified coders or LPNs.

As most of you know, I present on RACMonitor every week with a distinguished panel of experts. Last week, a listener asked whether 2 separate auditors could audit the same record. Dr. Ronald Hirsh’s response was: yes, a CERT can audit a chart that another reviewer is auditing if it is part of a random sample. I agree with Dr. Hirsh. When a random sample is taken, then the auditors, by definition, have no idea what claims will be pulled, nor would the CERT have any knowledge of other contemporaneous and overlapping audits. But what about multiple RAC audits? I do believe that the RACs should not overlap its own audits. Personally, I don’t like the idea of one claim being audited more than once. What if the two auditing companies make differing determinations? What if CERT calls a claim compliant and the RAC denies the claim? The provider surely should not pay back a claim twice.

I believe Ed Roche presented on this issue a few weeks ago, and he called it double-dipping.

This doesn’t seem fair. What Dr. Hirsh did not address in his response to the listener was that, even if a CERT is allowed to double-dip via the rules or policies, there could be case law saying otherwise.

I did a quick search on Westlaw to see if there were any cases where the auditor was accused of double-dipping. It was not a comprehensive search by any means, but I did not see any cases where auditors were accused of double-dipping. I did see a few cases where hospitals were accused of double-dipping by collecting DSH payments to cover costs that had already been reimbursed, which seems like a topic for another day.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on September 19, 2022, in Alleged Overpayment, CMS, Extrapolations, Federal Government, Knicole Emanuel, Medicaid, Medicaid Advocate, Medicaid Attorney, Medicaid Audits, Medicaid Providers, Medicaid Recoupment, Medicare, Medicare and Medicaid Provider Audits, Medicare Attorney, Medicare Audits, Medicare RAC, Post-Payment Reviews, RAC, RAC Audits, Tentative Notices of Overpayment and tagged , , , , , , , , , , , , . Bookmark the permalink. 1 Comment.

  1. Working under the 1915C waiver at a private home with family and Fiscal Management: Is it a requirement that the State Medicaid Agency provide the quality assurance of notice, remediation and full investigation without a notice of Fair Hearing for billing errors? What is the remedy? Should the State provide a CAP for their error and remediate this? The state says they can provide their own Criminal Code that is stricter and can deny the Federal Assurances in Pennsylvania. The OAG is arresting Direct Care workers instead of quality management and full investigation. Thanks

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