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Highmark, Ultra reports and Medicare Audits – handle them by yourself at your own risk (or, why smart Doctors lawyer up) June 1, 2011

Posted by jefhenninger in Articles.
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Medicare is a pain to deal with.  That’s why you love your billing manager so much right?  Well, if you get a letter from Highmark indicating that an ULTRA report shows an  aberrancy in your practice with regard to certain billing codes, I suggest you call a good Medicare fraud lawyer right away.  The problem with the initial letter from Highmark is that is not really that threatening.  It just lets you know that there is an issue.  For the most part, you don’t really have to even do anything; there is nothing to even fill out.  You could just file it away and ignore it right?

That could be a huge mistake.  Sometimes after the letter with the ULTRA report, you will be targeted for an audit.  The audit starts with a request for medical records for approximately 25 to 35 patients or services.  These medical records will be reviewed internally which will generate an analysis that either supports your utilization or determines that the services were not covered for a variety of reasons, i.e., medical necessity, failure to abide by policies such as mandatory surgical second opinions or some other cause such as fraud. You will then be permitted to submit additional information which can then be submitted to an outside reviewer.  Clearly, the big issue here is whether it appears that you are billing for services that did not occur or that you are intentionally over billing.

When records are requested, you should an attorney helping you through the process.  The records you initially supply will be used to determine whether you will be subject to a refund request and further review.  This could be your last opportunity to present all of the information necessary to support your actions in an attempt to avoid a costly audit and investigation.  Your attorney should help you decide what to say and how much information to provide although it generally helps to provide as much information as possible but the records have to be organized and easy to read/understand.  Your attorney may also have the records reviewed by an outside reviewer to bolster your position that your actions/practices are correct.

Please keep in mind that Medicare and Highmark can/will use the records that you have provided as a sample to generate refund requests covering the three year period prior to the services. For example, if 20 services are reviewed and it is determined that 10 of those services were unnecessary, then you may be subject to a refund request for 33% of all of the money that was paid for you for those services for the prior three years.  That could be a very large sum of money.

Of course, you can and should speak to your attorney about disputing the ULTRA report and not waiting for the audit.  First, review the ULTRA report to make sure that you are correctly characterized with regard to specialty as your practices are compared to your peer group (i.e. other physicians in your specialty).  I’ve had cases where Highmark’s ULTRA report was not correct because my client had a very unique practice and thus, the peer group was not correct.  You then need to review your billing practices with regard to those procedure codes in order to defend your practices or to revise that practice.   In other words, assume you had to testify tomorrow.  Would you be able to explain everything you did or your billing manager does?  Are all of your records in order?  Could you prove everything as if the burden of proof was on you?  You also want to see how far above the 95% percentile you are.  The closer you are to being off the charts, the greater the danger for not only an audit, but also a fraud investigation or prosecution.

Remember, even if you are found not guilty, your reputation is too important to risk.  Don’t handle this yourself.  Call a good attorney right away.

New Jersey Medicare Fraud Lawyers