IN THE BEGINNING
The ARRA (American Recovery & Reinvestment Act of 2009) was signed into law on February 17th, 2009 by the 111th US Congress. As most of you know the Medicaid and Medicare HIT EHR Incentives program was included as part of the HITECH ACT contained within the ARRA.
The earliest available date the actual program started was January 3, 2011. Although this was when the program started, not all states had completed building out their own provider portal systems. The individual provider portal system is where the application process or in technical terms 'attestation' takes place. When the program started there were only 8 states online (AK, IA, LA, MS, NC, SC, TN & TX). Remaining states would continue to come online with the slowest coming online as late as 2013.
While the provider portal build outs were in progress, participating states were charged with awarding contracts to their selected RAC.
A RAC is a Recovery Audit Contractor. The final date for states to select the RAC was January of 2012 and included the following requirement, ( A three-year maximum claims look-back period (§ 455.508(f)).
When the majority of states opened the gates from 2011 through 2012 it was a "come one come all environment". As the attestations began rolling in, so too, were the policies and procedures for detecting errors, inaccuracies and inconsistencies. Stronger processes for prepayment and post-payment audits were being developed in real time.
To begin gathering data initially, the States would conduct random audits. Through random audits the contractors began identifying patterns. They scoured attestations for weaknesses and shortcuts. They began identifying commonly fabricated forms of supporting documentation like false invoices, fake user agreements, non-patient volumes, lack of secured access to the appropriate software etc...
Soon the common denominators began to emerge to create the audit criteria currently employed in the review process.
BUILDING THE BEST CASE FOR RECOVERY
While the common mistakes list grew, the RAC contractors were required to communicate with their individual states and to all other RAC contractors throughout the US in the interest of streamlining processes on a national level to avoid duplicate efforts. The goal was to learn and share at an accelerated speed to shorten the length of the learning curve.
Going back to the beginning of the program in 2011. Add three years to that is 2014 (the maximum look back time). From an industry perspective the wave of audits truly began in 2013. RAC's had gathered enough data to begin honing in on potential ineligible provider over payments. So now through the end of the program there will be a push for recovery.
That said, the RAC contractors want the attestation submissions that yield the highest probability for recovery. Identifying those attestations with the highest probability comes from applying forensic analytics. Benford's Law and most recently the addition of Nigrinis Cycle. These are the mathematical formulas applied to accounting data that most accurately identify fraud, detect anomaly's and outliers. These formulas aren't just used in the US, they're used by countries, governments, policing agencies, private and public groups across the globe.
HOW THIS APPLIES TO YOU
Once the provider / corporation receives payment, the RAC has 3 years to look into it. Naturally the RAC wants the best possibility to get paid if they investigate it because their pay is based on a contingency fee. They need to identify the right accounts to look into at the start, otherwise, they are wasting their own time.
Ever wonder what an RAC makes from recovering a possible overpayment of $21,250.00 to an ineligible provider? In an article published in the Federal Register / Vol. 77, No. 37 / Friday, February 24, 2012 / Notices on page 11127
SO A $21,250 INCENTIVE PAYS A STAGGERING $3,718.75 TO THE RECOVERY AUDIT CONTRACTOR IF THEY RECOUP IT!
HERE'S THE TAKEAWAY!
RAC contractors don't have the resources or the need to perform 'random audits' anymore. So the 'random' audit is basically obsolete at this juncture. They'd rather sit at their desks and target known attestations that contain the red flag elements revealed by the forensic analytics processes. These are what I call the 'trip wires'!
As the founder and CEO of EHR Payment, I've studied hundreds of failed or failing audits to identify what causes them and how to address those situations through more specific supporting documentation practices. Understanding the audit side means my client's attestations will not contain audit trip wires - the same ones that cause delays, denials and, of course, audits.
I spend time gathering the highest and best supporting documentation which yields the very best outcome every time. I include two to three times as much documentation compared to the average EHR Vendor in every attestation I perform. I know inadequate and or insufficient documentation equals AUDITS! I gather the best documentation that establishes all of your relationships are in complete compliance with Federal and State specific guidelines.
My proprietary Medicaid EHR Payment Integrity Process® insures the best outcome now and in the future!
It's simple YOU DON'T GIVE THEM ANYTHING TO AUDIT!
This is how you avoid an EHR audit!
- Amanda "Mandy" Kerth
Call today 678-209-4256
EHR Payment Integrity Process®!
AVOID THE EHR
AUDIT TRIP WIRES