Since the OPI is a leader in the federal government's fraud and abuse efforts, we urge you to take positive steps to address physicians' concerns and correct the problems outlined below. A more prudent approach would be to focus on documented outliers. HCFA has assured the AMA time and time again that the agency is focused on substantive disputes and not on coding differences of one level. This is not what we are seeing from Medicare carriers and physicians across the country. Frequently, the carriers are focusing on coding differences of only one level.
Reasonable people can certainly disagree regarding such nuances.
A more prudent use of HCFA's resources than the pre-payment reviews would be for the agency to concentrate on the outliers. We are also concerned about reports of carrier error in the pre-payment reviews and throughout the audit process. The carrier down coded all five claims from level three to level one saying that there was inadequate documentation to support the higher level. When the physicians sent the carrier the guidelines, the claims were increased in value to a level four visit. In the pre-payment reviews, the carriers' correspondence requesting documentation does not adequately communicate to physicians the importance of responding .