Letter: Provider group accuses CMS of using Medicare audits for 'stealth policymaking' purposes

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Peter Budetti, Director of Program Integrity, the Centers for Medicare & Medicaid Services
Peter Budetti, Director of Program Integrity, the Centers for Medicare & Medicaid Services

A provider group is taking the Centers for Medicare & Medicaid Services to task for improperly using Medicare audits as a means of curtailing high-intensity therapy in skilled nursing facilities.

In a letter to Peter Budetti, M.D., deputy administrator and director of CMS' Center for Program Integrity, the American Health Care Association's Elise Smith, writes that the agency's antifraud Zone Program Integrity Contractors are targeting facilities that exceed limits of high-intensity therapy. AHCA views this as a “an abuse of the wide latitude provided for under the ZPIC authority and is essentially stealth policymaking without the benefit of dialogue with stakeholders.”

Smith, AHCA's senior vice president, finance policy and legal affairs, asserts that CMS used a 2010 Office of the Inspector General report — which found reported a surge in SNFs billing for high-intensity therapy — as a justification for heightened scrutiny of Medicare payments through audits.

Smith notes that the government's policy position on high-intensity therapy “fails to take into account numerous other market and regulatory changes in the post-acute marketplace,” and “misconstrues a SNF's role in determining what RUG category a patient is assigned to for purposes of Medicare billing.”

“The ongoing government investigations and ZPIC audits are an inappropriate attempt by the government to usurp the medical judgment of qualified practitioners and substitute its own flawed theories about patients with which the government is not actually familiar,” she wrote.

AHCA suggested modifications to the ZPIC audit process such as having auditors contact SNFs to make them aware of an investigation; guidelines that would establish a timeline for the Medicare contractor to follow during a pre-payment review; and a program that would allow providers the chance to contest pre-payment reviews.

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