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

Share this article:
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.

Share this article:
close

Next Article in News

More in News

Expert says providers often wrongly threatened by PEPPER reports

Instead of fearing further scrutiny by federal authorities, providers should embrace the opportunity to get feedback in the form of PEPPER reports, legal experts said Monday at the LeadingAge annual meeting in Nashville.

Healthcare reform already driving diverse, dynamic long-term care models, LeadingAge leaders say

Healthcare reform already driving diverse, dynamic long-term care ...

One way to gauge the effects is healthcare reform is by looking at ongoing changes to the continuing care retirement community model, LeadingAge officials said Monday at the association's annual ...

Federal court: Nursing home can be sued for firing hairdresser who can ...

Is the ability to transport residents in their wheelchairs an essential function of a nursing home hairdresser? A federal appeals court says it's a valid question and is allowing a hairdresser to sue a facility that fired her.