The Medicare Audit and Appeals Process: A Guide for Interventional Pain Practitioners

Abstract

Background: Health care is a highly regulated industry and interventional pain physicians (IPPs) are right in the government’s bull’s eye. Over the next few years, IPPs will find themselves responding to audit requests from Medicare. An IPP’s response to a Medicare record request should be tailored specifically to the type of request and the specific circumstances of the IPP. With so much at stake, IPPs should not underestimate the importance of an immediate and thoughtful response. Objectives: This article discusses 1) the various types of record requests used by Medicare, 2) the practical steps an IPP should take in response to a record request, 3) the Medicare appeals process, and, 4) the practical steps an IPP should take in connection with the appeals process. Discussion: IPPs should maintain an effective compliance program and ensure that medical records are appropriately documented before any audit takes place. If a Medicare audit decision is unfavorable, IPPs should understand the available appeals process and the steps that need to be taken to win the appeal. Conclusion: With advance preparation and a considered response, IPPs can positively influence the outcome of a Medicare audit. Key words: Medicare audit, appeals process, interventional pain management, interventional pain practitioners, Office of Inspector General (OIG), Comprehensive Error Rate Testing (CERT), Carrier Medical Review Program, Recovery Audit Contractor (RAC) audits