Source: http://www.willyancey.com/sampling-claims.html
Timestamp: 2017-08-18 16:30:21
Document Index: 277196884

Matched Legal Cases: ['§ 405', '§ 405', 'art 2', 'art 3', 'art 3', 'art 3', 'art 3', 'art 07', 'art 07', 'art 07', 'art 07', 'art 07', 'art 4', 'art 4', 'art 405']

ï»¿ Sampling for Medicare and Other Claims Sampling for Medicare and Other Claims
Dr. Yancey has testified as an independent expert on sampling and projection of Medicare claims and other health insurance claims.
Includes audits of processing of claims, such as Medicare, Medicaid, state-sponsored health care plans, group health care claims, other insurance claims, and government programs.
Disclaimer: Inclusion in this list does not imply the reference is or was a reliable authority or relevant to any particular set of facts. Omission from this list does not imply the item was not reliable. Links to consultants does not imply endorsement.
Maintained by ACLR. Please e-mail your suggestions for additions and changes to wyancey@aclrsbs.com.
Regulatory Authority related to sampling Medicare or Medicaid claims
Medicare and Medicaid Payment Reviews - DHHS and CMS Policy
Medicare and Medicaid Payment Reviews - DHHS Office of Inspector General (OIG)
Medicaid and State Health Care Programs
Oversight by Federal, State, and Nongovernmental Organizations and Policy Analysts
Medicare Zone Program Integrity Contractors (ZPIC) and Program Safeguard Contractors
Medicare Part D Medicare Drug Integrity Contractor (MEDIC)
Department of Health and Human Services (DHHS) Appeals Board
Health Care Claim Overpayments - Secondary Authority - Articles and Books
Coding Health Care Claims
Consultants on Medicare, Medicaid, and Health Care Bill Auditing
Law Firms Representing Providers in Medicare Overpayment Disputes
Publishers, Associations, and Conference Organizers
Sampling Design Issues in Sales and Use Tax Audits
Sampling for Financial and Internal Audits
Sampling in Sales and Use Tax Audits - Review Articles
Sampling in Sales and Use Tax Audits - State-Specific References
42 U.S.C. 1395ddd, "Medicare Integrity Program", subsections (a) through(e), added by Section 202(b) of the P.L. 104-191, Health Insurance Portability and Accountability Act (HIPPA) of 1996. DHHS authorized to promote the integrity of the Medicare program by entering into contracts. The contractors may review for Medicare overpayments.
42 U.S.C. 1395ddd, subsection (f), "Recovery of Overpayments" added by Section 935 of the P.L. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Title IX. Conference Committee House Report 108-391, filed November 21, 2003. DHHS required to specify procedures for Medicare overpayment recovery audits. DHHS must develop a standard methodology for selection of sample claims for abnormal billing patterns. The statute provides general guidance on the use of a "statistically valid random sample" (SVRS).
42 U.S.C. 1395ddd (f) (3) Limitation on use of extrapolation
A medicare contractor may not use extrapolation to determine overpayment amounts to be recovered by recoupment, offset, or otherwise unless the Secretary determines that -
42 U.S.C. 1395ff, subsection (d), "Deadline for Hearings by the Secretary" added by P.L. 106-554 Consolidated Appropriations Act 2001, H.R. 5661 Benefits Improvement and Protection Act (BIPA) of 2000, Section 521 Revisions to Medicare Appeals Process. (d)(1)(A) "... an administrative law judge shall conduct and conclude a hearing on a decision of a qualified independent contractor under subsection (c) and render a decision on such hearing by not later than the end of the 90-day period beginning on the date a request for hearing has been timely filed."
42 U.S.C. 1874A, subsection (h), "Conduct of Prepayment Review", added by Section 934 of the P.L. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Title IX. Conference Committee House Report 108-391, filed November 21, 2003. DHHS required to develop guidelines on use of random and non-random prepayment reviews.
Section 306, "Demonstration Project for Use of Recovery Audit Contractors" of P.L. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Title III. DHHS authorized to begin demonstration project using recovery audit contractors under the Medicare Integrity Program in identifying underpayments and overpayments and recouping overpayments.
Section 941, "Policy Development Regarding Evaluation and Management (E&M) Documentation Guidelines" of P.L. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, Title IX. DHHS authorized to develop projects and guidelines on documentation of claims.
Erroneous Payments Recovery Act of 2001, H.R. 2547, Added to P. L. 107-107, H.R. 2586, National Defense Authorization Act for Fiscal Year 2002, Title VIII, Subtitle B, Sections 811-819. Requires recovery audit programs for federal government agencies with contracts greater than $500 million per fiscal year.
Improper Payments Information Act of 2002, H. R. 4878, P. L. 107-300. Requires each agency, for each program or activity with estimated improper payments exceeding $10 million, to provide with the estimate a report on agency actions to reduce such improper payments, including: (1) a discussion of the causes of the improper payments and results of the actions taken to address those causes; (2) a statement of whether the agency has the information systems and other infrastructure it needs to reduce such payments to minimal cost-effective levels and, if not, a description of the resources the agency has requested to obtain necessary systems and infrastructure; and (3) a description of the steps the agency has taken to ensure that managers are held accountable for reducing improper payments.
42 CFR Â§ 405. Federal Health Insurance for the Aged
42 CFR Â§ 405.1064 ALJ decisions involving statistical samples. When an appeal from the QIC involves an overpayment issue and the QIC used a statistical sample in reaching its reconsideration, the ALJ must base his or her decision on a review of the entire statistical sample used by the QIC.
Administrative Authority - US Department of Health and HumanServices
The Centers for Medicare and Medicaid Services (CMS) was formerly known as the Health Care Financing Administration (HCFA). HCFA was renamed CMS in June 2001.
Most of the documents on overpayment audits and sampling are included in Manuals or Program Transmittals.
Program Transmittals are at www.cms.hhs.gov/Transmittals/
Program Manuals are at www.cms.hhs.gov/Manuals/
Acronyms at the www.cms.hhs.gov/apps/acronyms/
News media release database at www.cms.hhs.gov/apps/media/
Press releases at www.cms.hhs.gov/apps/media/press_releases.asp
Fact sheets at www.cms.hhs.gov/apps/media/fact_sheets.asp
Testimony on Medicare and Medicaid Fraud by Penny Thompson, Program Integrity Director, Health Care Financing Administration before the House Budget Committee Health Care Task Force, July 12, 2000, www.hhs.gov/asl/testify/t000712b.html
Health Care Financing Administration (HCFA) Program Manuals, issued and revised prior to June 2001
Publication 13, Medicare Intermediary Manual, Part 2, Chapter VII, section 2690, Sampling Guidelines for Admissions Pattern Monitoring
Publication 13, Medicare Intermediary Manual, Part 3, Chapter V, sections 3434.4 to 3434.6, Sampling Guidelines for Intermediaries
Publication 14, Medicare Carrier Manual, Part 3 - Claims Process, Part 3 Table of Contents
Part 3, Chapter VII, "Payment and Post Payment Procedures, Chapter VII Table of Contents
The Chapter VII Appendix on Sampling Guidelines was issued in 1975. The Sampling Guidelines were superseded by Program Memorandum Transmittal B-01-01, issued on January 8, 2001.
Publication 45, State Medicaid Manual, Part 07 - Quality Control, Part 07 Table of Contents
Part 07 - Sections 7100 to 7124. Describes how sampling is used in the Medicaid Eligibility Quality Control (MEQC) system to validate eligibility of the total caseload and determine the dollar value of errors.
Part 07 - Sections 7125 to 7154. Describes more details of the sampling methods and documentation.
Part 07 - Appendix A. Contains glossary of terms, sampling methods, error rate calculation, and lower limit of confidence interval.
Publication 100-6, Medicare Financial Management Manual, Chapter 3 - Overpayments
Section 50. Referral to the Department of Justice - (Rev. 3, 08-30-02), A2-2228 Section 50. Subsection B - Paragraph 3(c). Documentation of Referred Overpayments - Overpayments Resulting from Excessive Utilization. Where overpayments as a result of excessive utilization are discovered, the fiscal intermediary (FI) shall provide documentation including all communications,relative to the development of the sample, explanation of the techniques used, projected statistical sample results, and medical review; provider's acceptance of the sampling techniques and the resulting overpayment determination; and other documents.
Publication 100-6, Medicare Financial Management Manual, Chapter 9 - Intermediary Procedures for Provider Audit
Section 60.4.2 Evidence - (Rev. 9, 08-30-02), A4-4112.4 ...Subsection B. 1.(e). Discusses sample planning, selecting a sampling approach, and sampling risk.
Publication 100-8, Medicare Program Integrity Manual (PIM), PIM Table of Contents
Chapter 3, Section 6, Postpayment Review of Claims for MR Purposes. Describes overpayment review procedures.
Chapter 3, Section 7, Sampling Exhibits. Presents examples of sampling notification letter, sample selection procedures, and other aspects of sampling.
Chapter 3, Section 8, Overpayment Procedures. Describes procedures for projecting overpayments from a Statistically Valid Random Sample (SVRS).
CMS Program Manuals issued after June 2001
Program Manuals in zipped or PDF format are online at www.cms.hhs.gov/Manuals/
Publications numbered less than 100 are in the Paper Based Manual (PBM) section.
Publications numbered 100 are in the Internet-Only Manual (IOM) section.
Publication 45, State Medicaid Manual,
State Medicaid Manual - Chapter 7, Quality Control, www.cms.hhs.gov/manuals/downloads/P45_07.zip
State Medicaid Manual - Chapter 8, Program Integrity, www.cms.hhs.gov/manuals/downloads/P45_08.zip
Publication 100-04, Medicare Claims Processing Manual
Medicare Claims Processing Manual - Chapter 33, Miscellaneous Hold Harmless Provisions, www.cms.hhs.gov/manuals/downloads/clm104c33.pdf
Publication 100-06, Medicare Financial Management Manual
Medicare Financial Management Manual - Chapter 3, Overpayments, www.cms.hhs.gov/manuals/downloads/fin106c03.pdf
Medicare Financial Management Manual - Chapter 8, Contractor Procedures for Provider Audits, www.cms.hhs.gov/manuals/downloads/fin106c08.pdf
Publication 100-08, Medicare Program Integrity Manual
Medicare Program Integrity Manual - Chapter 3, Verifying Potential Errors and Taking Corrective Actions, www.cms.hhs.gov/manuals/downloads/pim83c03.pdf
Publication 100-13, Medicare Intermediary Manual
Medicare Intermediary Manual - Part 4, Audit Procedures, www.cms.hhs.gov/manuals/downloads/P13_04.zip
Publication 100-14, Medicare Carriers Manual
Medicare Carriers Manual - Part 4, Audit Procedures, www.cms.hhs.gov/manuals/downloads/P14_04.zip
The Program Transmittals related to sampling are revisions to Medicare Manuals.
Program Transmittals are online at www.cms.hhs.gov/Transmittals/
Selected HCFA and CMS Rulings are posted at http://www.cms.hhs.gov/Rulings/CMSR/list.asp
HCFA Ruling 86-1, "HCFAR Use of Statistical Sampling to Project Overpayments to Providers and Suppliers", effective February 20, 1986. Reviews existing law and finds authority to use statistical sampling to project an overpayment is consistent with common law, Medicare statute, and Department regulations. Sampling does not deprive a provider of due process. A case-by-case review is not required to determine the amount of overpayment. [After HCFA changed to CMS this ruling can be cited as CMS Ruling 86-1 or CMSR 86-1. Cited in Transmittal B-03-022, March 21, 2003, www.cms.hhs.gov/transmittals/downloads/B03022.pdf, "Use of Statistical Sampling for Overpayment Estimation When Performing Administrative Reviews of Part B Claims".]
Transmittal AB-00-72, August 7, 2000, www.cms.hhs.gov/transmittals/downloads/AB0072.pdf, "Medical Review Progressive Corrective Action (PCA)". Provides general guidance on conducting medical reviews and estimating provider error rates. Discusses the use of "probe reviews" with small samples to determine if further investigation is needed.
Transmittal B-01-01, January 8, 2001, www.cms.hhs.gov/transmittals/downloads/B0101.pdf, "Use of Statistical Sampling for Overpayment Estimation When Performing Administrative Reviews of Part B Claims".
Transmittal B-02-007, February 7, 2002, www.cms.hhs.gov/transmittals/downloads/B02007.pdf, "Use of Statistical Sampling for Overpayment Estimation When Performing Administrative Reviews of Part B Claims". Reissue of Transmittal B-01-01 with extension of discard date to February 9, 2003.
Transmittal B-03-022, March 21, 2003, www.cms.hhs.gov/transmittals/downloads/B03022.pdf, "Use of Statistical Sampling for Overpayment Estimation When Performing Administrative Reviews of Part B Claims". Reissue of Transmittal B-01-01 with extension of discard date to March 20, 2004.
Transmittal 60, November 26, 2004, www.cms.hhs.gov/transmittals/Downloads/R60FM.pdf, "Revised instructions on contractor procedures for provider audit and the Provider Statistical & Reimbursement Report (PSRR)".
Transmittal 108, April 29, 2005, www.cms.hhs.gov/transmittals/downloads/R108PI.pdf "Change in Statistical Sampling Instructions". Effective date December 8, 2004. Implements Medicare Modernization Act (MMA) section 935 (a).
Transmittal 114, June 10, 2005, www.cms.hhs.gov/transmittals/downloads/R114PI.pdf "Change in Statistical Sampling Instructions". Minor revision of Transmittal 108.
Transmittal 123, September 23, 2005, www.cms.hhs.gov/transmittals/downloads/R123PI.pdf "Change Request 3703". After Medicare administrative contractors have identified overpayment problems with providers, they may request a limited sample of documentation of subsequent claims to test whether the problem has been resolved. For a provider specific problem the sample may be random or stratified and consist of 20 to 40 claims. For systemic problems with multiple providers the sample size should generally be 100.
Transmittal 184, January 26, 2007, www.cms.hhs.gov/transmittals/downloads/R184PI.pdf "Change Request 5399". This transmittal makes minor revisions in the Medicare Program Integrity Manual Chapter 3 by updating references to Medicare contractors and affiliates.
Transmittal 322, March 5, 2008, www.cms.hhs.gov/transmittals/downloads/R322OTN.pdf "Change Request 5873", This updates the guidance to Medicare contractors on recoupment under section 935 of the Medicare Modernization Act of 2003.
Open Door Forums ...dialogues between CMS and provider community
Open Door Forum homepage
Corporate Integrity Agreements (CIA) ...includes comments on sampling requirements
Frequently Asked Question 4: CIA Claims Reviews ...includes sampling requirements
Health Care Fraud and Abuse Control Program Report (HCFAC) ...annual reports
Audit Reports on Centers for Medicare and Medicaid Services ...published audit reports on hundreds of providers
RAT-STATS ...software provided by OIG-OAS
The Deficit Reduction Act of 2005 created the Medicaid Integrity Program (MIP) to coordinate national strategy on Medicaid fraud and abuse.
California Medi-Cal ...California Department of Health Care Services
Medi-Cal Audits and Investigations
Medi-Cal Audits and Investigations - publications ...Stop Medi-Cal Fraud
Medi-Cal Pre-Checkwrite Review of Claims - random sampling
Centers for Medicare and Medicaid Services (CMS) - Medicaid Management Information System (MMIS)
Centers for Medicare and Medicaid Services (CMS) - Payment Error Rate Measurement (PERM) ...error data for Medicaid and State Children's Health Insurance Programs
Centers for Medicare and Medicaid Services (CMS) Publications
State Medicaid Directors Letters
State Health Official Letters
DHHS Office of Inspector General(OIG) - Medicaid Fraud Control Unit publications
Medicaid Benefits Online Database ...by Kaiser Family Foundation
Medicaid Integrity Institute (MII) ...developed by the Centers for Medicare & Medicaid Services (CMS) in collaboration with the U.S. Department of Justice, Office of Legal Education to meet the training and education needs of state Medicaid program integrity employees. The MII is located at the National Advocacy Center (NAC) in Columbia, South Carolina on the campus of the University of South Carolina.
Medicaid News - health professionals ...an EIN news service
Medicaid News - political professionals ...an EIN news service
National Association of Medicaid Fraud Control Units (NAMFCU) ... affiliated with the National Association of Attorneys General (NAAG)
NAMFCU directory ...state MFCU directors
National Association for Medicaid Program Integrity (NAMPI)
NAMPI directory ...state MPI directors
NASMD directory ...state Medicaid websites
National Senior Citizens Law Center (NSCLC) - Medicaid program news
New York State Medicaid ...New York State Department of Health
StateHealthFactors.org ...by Kaiser Family Foundation
Texas Health and Human Service Commission (HHSC) Office of Inspector General (OIG)
Administration on Aging (AOA) ...an agency of the US Department of Health and Human Services
Brookings Institution ...a non-profit public policy research foundation
Cato Institute ...a non-profit public policy research foundation
CMS Acronym Finder and Glossary
CMS Research, Statistics, Data & Systems - home page
Comprehensive Error Rate Testing (CERT) ...error data for Medicare error data
CERT Documentation Center ...Medicare error data collection managed by Livanta LLC
ExpectMore.gov ...developed by the U.S. Office of Management and Budget and Federal agencies
Medicare Integrity Program - summary
Medicare Integrity Program - detailed information ...includes table on Medicare contractor error rates
Federal Trade Commission on Health Care Competition
George Washington University School of Public Health and Health Services - National Health Reform Law and Policy Project
Government Accountability Office (GAO) ...the investigative agency of the US Congress
Health Research Institute ...PricewaterhouseCoopers
House Committee on Energy and Commerce ...Congressional hearings and bills related to Medicare
InsideHealthPolicy.com/ ...publisher of health care policy news
Medicare Claim Review Programs: MR, NCCI Edits, MUEs, CERT, and RAC ...CMS booklet
Medicare Payment Advisory Commission (MedPAC) ...an independent federal body established by the Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress on issues affecting the Medicare program.
Payment Error Rate Measurement (PERM) ...error data for Medicaid and State Children's Health Insurance Programs (SCHIP)
Senate Committee on Health, Education, Labor & Pensions (HELP) ...Congressional hearings and bills related to Medicare
Medicare claims processing is provided by Medicare Administrative Contractors (MAC), as authorized by Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173).
CMS awards contracts to the MAC for specific coverage types and geographic areas.
Most MAC have contracts for several coverage types and several geographic areas.
Most MAC are or were affiliated with the 39 member companies of the Blue Cross & Blue Shield Association ("the Blues") or their contractors.
Medicare in the United States is described at http://en.wikipedia.org/wiki/Medicare_%28United_States%29
The Blue Cross & Blue Shield companies are described at http://en.wikipedia.org/wiki/Blue_cross_blue_shield
Medicare Administrative Contractors (MAC) were formerly known as Medicare Carriers and Fiscal Intermediaries.
Carriers made Medicare payments to providers including doctors and equipment suppliers.
Fiscal Intermediaries made Medicare payments to facilities such as hospitals and nursing facilities.
Railroad Retirement Board Carriers (RRBC) administer benefits for railroad retirees.
Medicare Part A Hospital Insurance Intermediaries administer payments to hospitals, skilled nursing facilities (SNF), community mental health centers (CMHC), and other facilities.
Medicare Part A Regional Home Health Intermediaries (RHHI) administer payments to home health agencies.
Medicare Part A Rural Health Clinic Intermediaries (RHCI) administer payments to rural clinics.
Medicare Part B Medical Insurance Carriers administer payments to individual doctors, clinics, and equipment providers.
Medicare Part B Durable Medical Equipment Regional Carriers (DMERC) administers payments to medical equipment suppliers.
Medicare Part C, also known as Medicare+Choice or Medicare Advantage, provide supplements to Parts A and B.
Medicare Part D carriers provide prescription drugs, preventive screenings, and some medical tests.
CMS Intermediary-Carrier Directory
CMS Medicare Contractor Website Index
AdminaStar Federal ...now part of National Government Services
Anthem Health Plans of New Hampshire (AHPNH) ...now part of National Government Services
Arkansas Medicare Services ...a subsidiary of Arkansas BlueCross BlueShield
Associated Health Services (AHS) ...now part of National Government Services
Cahaba Government Benefit Administrators ...a subsidiary of BlueCross BlueShield of Alabama
Carefirst ...BlueCross BlueShield affiliate in Maryland, the District of Columbia and northern Virginia
Empire Medicare Services ...now part of National Government Services
First Coast Service Options, Inc. (FCSO) ...a subsidiary of Blue Cross and Blue Shield of Florida
Group Health, Inc. (GHI)
HGSAdministrators ...part of Highmark Medicare Services
Highmark Medicare Services ...BlueCross BlueShield affiliate in Pennsylvania and West Virginia
Louisiana Medicare Services ...a subsidiary of BlueCross BlueShield of Louisiana
Mutual Medicare ...Mutual of Omaha
National Government Services ...the Medicare business of Wellpoint
National Heritage Insurance Company (NHIC) ...a subsidiary of EDS, that is now part of Hewlett Packard - HP Enterprise Services
Palmetto Government Benefits Administrators, LLC ...a subsidiary of BlueCross BlueShield of South Carolina
Pinnacle Business Solutions, Inc. (PBSI) ...a subsidiary of Arkansas BlueCross BlueShield
Regence ...BlueCross BlueShield affiliate in Oregon, Washington, Idaho, and Utah
Riverbend Government Benefits Administrator ...a subsidiary of BlueCross BlueShield of Tennessee
TrailBlazer Health Enterprises, LLC ...a subsidiary of BlueCross BlueShield of South Carolina
Triple S, Inc. ...BlueCross BlueShield affiliate in Puerto Rico
TriSpan Health Services ...BlueCross BlueShield of Mississippi
United Government Services, LLC ...now part of National Government Services
Veritus Medicare Services ...became Highmark Medicare Services
The Recovery Audit Contractor (RAC) demonstration program was authorized by section 306 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173). The program is made permanent by section 302(h) of the Tax Relief and Health Care Act of 2006 (P. L. 109-432).
RACs identify and collect Medical claims overpayments and underpayments that were not previously identified by the MACs.
CMS has contracts with 4 RACs. Each RAC is responsible for identifying overpayments and underpayments in its assigned region.
For more information see https://www.fbo.gov/index and Medicare and Medicaid Payment Reviews - DHHS and CMS Policy
Announcements about RAC program
CMS web page for RAC program
Guidelines for RAC are in the Medicare Secondary Payer Manual at http://www.cms.hhs.gov/manuals/downloads/msp105c08.pdf
Congressional request for oversight on RAC program ...Congresswoman Lois Capps
Contractors for RAC program
RAC contact information.
CGI Technologies and Solutions, Inc. ...RAC contractor for Region B (Midwestern States: initially working in Michigan, Indiana and Minnesota)
Connolly Healthcare ...RAC contractor for Region C (Southern States: initially working in South Carolina, Florida, Colorado and New Mexico).
Connolly may subcontract some work to Viant
DCS Healthcare ...RAC contractor for Region A (Eastern States: initially working in Maine, New Hampshire, Vermont, Massachusetts, Rhode Island and New York).
Diversified Collection Services, Inc. (DCS) is a subsidiary of Performant Financial Corporation
Health Data Insights, Inc. ...RAC contractor for Region D (Plains States: initially working in Montana, Wyoming, North Dakota, South Dakota, Utah and Arizona)
PRG-Schultz ...PRG was in the RAC demonstration project, but was not awarded a new RAC contract. PRG subcontracted some RAC work to Concentra, that merged into Viant
Advice for providers in RAC audits
Castle Rock Medical Group (CRMG)
Recovery Audit Contractor Workbook (eBook), by Arpana Narain, MPH with David Butler, Rita Isnar JD, MPA and Deborah Rubbens Hutchinson JD, LLM, CCH Health, published January 2009.
Medicare providers have a five-step appeals process described at www.hhs.gov/omha/levels/index.html
Regulations for this appeals process are in the Code of Federal Regulations, Title 42, Chapter IV, Part 405, Sections 405.201 through 405.2472.
See the Code of Federal Regulations at http://www.findlaw.com/casecode/cfr.html or http://www.access.gpo.gov/nara/cfr/cfr-table-search.html.
Level 1: After the PSC or ZPIC initial determination, the provider can request a redetermination from a Hearing Officer of the Medicare Administrative Contractor
Level 2: After the MAC redetermination, the provider can request a reconsideration by a designated Qualified Independent Contractor (QIC)
Level 3: After the QIC reconsideration, the provider can request a hearing by an Administrative Law Judge (ALJ) of the Office of Medicare Hearings and Appeals (OMHA)
Level 4: After the ALJ hearing, the provider can request a review by the Medicare Appeals Council of the DHHS Departmental Appeals Board (DAB)
Level 5: After the DAB review, the provider can litigate in federal district court. See Litigation in Federal and State Courts
The Medicare Part C Managed Care appeals process is described at www.cms.hhs.gov/MMCAG/
The contractors' legal authority was approved by GAO General Counsel Decision B-282777 on September 2, 1999, http://www.gao.gov/decisions/archive/282777.pdf
See the Frequently Asked Questions (FAQs) by CSC.
See the Benefit Integrity commentary by Highmark.
Prior to 2003, the Medicare contractors's own benefit integrity (BI) departments did this type of work. Most benefit integrity functions are now done by other contractors.
In 2002 to 2009, the Program Safeguard Contractors (PSC) conducted Medicare Part A (hospitals, skilled nursing facilities, etc.) and Part B (physicians, labs, therapists, ambulance services, etc.) fraud and overpayment reviews on behalf of the Medicare Administrative Contractors (MAC).
In 2008 and 2009 the PSC contracts are being phased out and replaced with Zone Program Integrity Contractors (ZPIC). Some of the companies that had PSC contracts will have ZPIC contracts. ZPIC contractors will have responsibility for Medicare (Part A, B, DME, Home Health and Hospice) and Medicare Medicaid Data Matching (Medi Medi) Programs.
Each ZPIC contract is expected to run for five years. ZPIC contracts are awarded in three cycles. Cycle 1 for zones 4, 5, and 7. Cycle 2 for zones 1 and 2. Cycle 3 for zones 3 and 6.
ZPIC regions
ZPIC Zone 1: California, Nevada, American Samoa, Guam, Hawaii, and the Mariana Islands. To be awarded by the end of 2009.
ZPIC Zone 2: Alaska, Washington, Oregon, Montana, Idaho, Wyoming, Utah, Arizona, North Dakota, South Dakota, Nebraska, Kansas, Iowa and Missouri. On September 30, 2009 awarded to AdvanceMed
ZPIC Zone 3: Minnesota, Wisconsin, Illinois, Indiana, Michigan, Ohio, and Kentucky. To be awarded in 2010.
ZPIC Zone 4: Texas, Oklahoma, Colorado, and New Mexico. On October 2, 2008 awarded to Health Integrity, LLC, owned by Delmarva Foundation who has done contracts with AdvanceMed
ZPIC Zone 5: West Virginia, Virginia, North Carolina, South Carolina, Georgia, Alabama, Mississippi, Tennessee, Arkansas, and Louisiana. On February 4, 2009 awarded to AdvanceMed
ZPIC Zone 6: Pennsylvania, New York, Maryland, Washington DC, Delaware, Maine, Massachusetts, New Jersey, Connecticut, Rhode Island, New Hampshire, Vermont. To be awarded in 2010.
ZPIC Zone 7: Florida, Puerto Rico, and the U.S. Virgin Islands. On October 2, 2008 awarded to Safeguard Services (SGS) and its subcontractor IntegriGuard, LLC, a subsidiary of HMS Holdings
Names of ZPIC and PSC contractors
All of the PSC or ZPIC are or were owned by, affiliated with, have many employees from, or contracted to Medicare administrative contractors.
Some of the companies listed below are no longer serving as a PSC or ZPIC.
AdvanceMed ...subsidiary of Computer Sciences Corporation (CSC)
Aspen Systems Corporation ...acquired by Lockheed Martin Information Technology
Cahaba Safeguard Administrators, LLC ...a subsidiary of BlueCross BlueShield of Alabama
California Medical Review, Inc. (CMRI) ...became Lumetra
Computer Sciences Corporation (CSC): Government Health Services
DynCorp ...AdvanceMed was formed in 2001 from DynCorp's Medicare claims business
Health Integrity, LLC ...affiliated with Quality Health Strategies, Inc. (QHS), Delmarva Foundation and AdvanceMed
IntegriGuard, LLC ...formed by Lumetra and sold to HMS Holdings in 2009
Lifecare Management Partners, Inc. ...located in Alexandria, Virginia
Lumetra ...formerly CMRI. Sold its IntegriGuard, LLC to HMS Holdings
Mutual Medicare ...owned by Mutual of Omaha
Safeguard Services, LLC (SGS) ...a subsidiary of EDS, that is now part of Hewlett Packard - HP Enterprise Services
Safeguard Solutions, Inc. ...affiliated with Empire Medicare Services, a unit of Wellpoint
Science Applications International Corp (SAIC): Health Care ...through subsidiaries including MEDPROTECT, LLC
TriCenturion ...TriCenturion formerly was the PSC for Texas. TriCenturion is a joint venture of BlueCross BlueShield of South Carolina and BlueCross BlueShield of Florida
Trust Solutions LLC ...affiliated with Wisconsin Physicians Service Insurance Corporation (WPS)
United Government Services, LLC ...now part of National Government Services, a unit of Wellpoint
Western Integrity Center
Medicare Part D Prescription Drug Integrity Contractor (MEDIC)
Medicare Prescription Drug appeals process is described at www.cms.hhs.gov/MedPrescriptDrugApplGriev/
The Part D appeals process is similar to appeals for Medicare Part A (hospitals) and Part B (phyicians and clinical services) fraud and overpayment reviews.
The national phone number to reach the regional MEDIC programs is (877) 772-3379.
The following companies are or were MEDIC prime contractors or subcontractors.
EDS Safeguard Services ...a subsidiary of EDS Corporation
Health Integrity, LLC - MEDIC ...affiliate of Delmarva Foundation
IntegriGuard - MEDIC ...a subsidiary of Lumetra
StrategicHealthSolutions, LLS ...a subcontractor of MEDPROTECT, IMPAQ International, and Maximus
The QIC hear second-level appeals (also known as reconsiderations) from Medicare providers who are disputing the results of the MAC redetermination.
A provider may appeal a QIC decision to an Administrative Law Judge
See the QIC Fact Sheet provided by CMS.
The Centers for Medicare & Medicaid Services (CMS) awarded an Indefinite Delivery/Indefinite Quantity (IDIQ) contracts to seven entities to perform QIC functions. Under this contract, CMS competitively awarded the following task orders:
Administrative QIC (Q2 Administrators)
Part A East QIC (Maximus)
Part A West QIC (Maximus)
Part B North QIC (First Coast Service Options)
Part B South QIC (Q2 Administrators)
Durable Medical Equipment QIC (RiverTrust Solutions)
Part C QIC (Maximus)
Part D East QIC (Maximus)
Part D West QIC (Maximus)
IntegriGuard ...a subsidiary of Lumetra
MAXIMUS Federal Services, Inc. - Center for Health Dispute Resolution ...subisidiary of a publicly-traded government consulting services company
StrategicHealthSolutions, LLC performs reconsideration appeals on Medicare Part C as a subcontractor to Maximus
Q2 Administrators, LLC ...a subsidiary of BlueCross BlueShield of South Carolina
RiverTrust Solutions, Inc. ...subsidiary of BlueCross BlueShield of Tennessee
Administrative Law Judges (ALJ) hear appeals of Medicare overpayment reviews.
Prior to 2005 the ALJ who heard these appeals were in the Social Security Administration (SSA) Office of Hearings and Appeals (OHA).
After 2005, Medicare appeals are heard by the DHHS Office of Medicare Hearings and Appeals (OMHA), http://www.hhs.gov/omha/
The OMHA has four regional offices and each hears cases for specific regions as shown at http://www.hhs.gov/omha/about/contacts/offices.html
After the ALJ hearing, the provider may appeal to the Department of Health and Human Services (DHHS) Appeals Board
A few ALJ decisions on sampling and extrapolation issues in Medicare overpayment reviews are cited below.
Copies of ALJ decisions may be available after the names and identifying information of beneficiaries have been redacted.
MK Diabetic Support Services and RespiFlow, Inc., Consolidated Case Docket No. 000-47-3975, (Decision October 15, 1998, ALJ Robert S. Habermann). Held the overpayment sampling methodology used by the carrier was invalid.
Morrow Skin Clinic and David M. Morrow, MD,. Inc., (Decision December 20, 1994, ALJ Kenneth E. Stewart). Held the carrier's overpayment extrapolation methodology was invalid.
Stuart Guttman, MD, (Decision August 15, 2005, ALJ Jon D. Boltz). Held that a sample of 15 beneficiaries is not a statistically valid sample under the Medicare standards or generally accepted statistical sampling methods.
Total Renal Laboratories, (Decision September 21, 2004, ALJ Ronald T. Osborn). Held the sampling estimation method used by the carrier was invalid. Carrier could collect only the specific overpayments identified and could not extrapolate to the population.
Selected Medicare appeals decisions are posted by the Department of Health and Human Servcies (DHHS) Departmental Appeals Board (DAB) at http://www.hhs.gov/dab/macdecision/
Some DAB rulings are searchable at http://www.hhs.gov/dab/search.html
Selected rulings related to statistical sampling and projection are cited below.
HCFA Ruling 86-1, "HCFAR Use of Statistical Sampling to Project Overpayments to Providers and Suppliers", effective February 20, 1986. Reviews existing law and finds authority to use statistical sampling to project an overpayment is consistent with common law, Medicare statute, and Department regulations. Sampling does not deprive a provider of due process. A case-by-case review is not required to determine the amount of overpayment. [After HCFA changed to CMS this ruling can be cited as CMS Ruling 86-1 or CMSR 86-1. Cited in Transmittal B-03-022, March 21, 2003, www.cms.hhs.gov/transmittals/downloads/B03022.pdf, "Use of Statistical Sampling for Overpayment Estimation When Performing Administrative Reviews of Part B Claims".
Departmental Appeals Board, Grant Appeals Board, Tennessee Department of Health and Environment, DAB No. 898, (September 11, 1987), http://www.hhs.gov/dab/decisions/dab898.txt
Departmental Appeals Board, Civil Remedies Division, Keith O. Irby and Michelle P. Irby, R. Ph., Docket C-243, Decision No. CR321 (July 13, 1994), http://www.hhs.gov/dab/decisions/cr-321.htm
Departmental Appeals Board, Medicare Appeals Council, Samuel Nigro, MD, (April 30, 2001) http://www.hhs.gov/dab/macdecision/Nigro.html
Departmental Appeals Board, Medicare Appeals Council, Metro Home Care, (December 17, 2001) http://www.hhs.gov/dab/macdecision/metrohomecare.html
Departmental Appeals Board, Medicare Appeals Council, Vascular Diagnostic Center and Vascular Testing Center, (April 17, 2003) at http://www.hhs.gov/dab/macdecision/vascdiagcntr.html
Departmental Appeals Board, Medicare Appeals Council, Critical Care of North Jacksonville, (February 29, 2008) at http://www.dhhs.gov/dab/macdecision/Reopening022908.pdf
The PRRB is an independent panel to which a certified Medicare provider of services may appeal if it is dissatisfied with a final determination of its fiscal intermediary or the appeal to CMS.
PRRB Home Page
PRRB Decisions
AllCare Home Health, Inc. (Denver, Colorado), PRRB Decision No. 2000-D9 (December 9, 1999), www.cms.hhs.gov/PRRBReview/downloads/2000D9.pdf. Intermediary adjusted a provider's owner compensation based on the Michigan compensation survey data. Provider's expert challenged the study's small sample size and low response rate. The PRRB ruled the Michigan compensation survey was not valid for this particular provider.
Hospital San Fransisco, Inc. (Rio Pedras, Puerto Rico), PRRB Decsion No. 2003-D57 (September 12, 2003), www.cms.hhs.gov/officeattorneyadvisor/downloads/2003-D57R.pdf. Intermediary denied a hospital's bad debt adjustment based on a sample of 9 patients out of a 1,099 patient population. The PRRB ruled the sample size was too small, and adjusted the result to only those 9 patients rather than allowing a projection to the population.
Listed alphabetically by plaintiff's name.
Chaves County Home Health Service, Inc. v. Sullivan, 931 F.2d 914 (DC Cir. 1991), cert. denied 502 US 1091, 112 S.Ct. 1160(1992).
Chaves County Home Health Service, Inc. v. Sullivan, 723 F.Supp 188 (D. C. District 1990).
See discussion of Chaves case in Fowler, Janet F., James E. Foster, Lisa S. Foley, and Alan H. Kvanli, "Statistics, the Law and Government Auditors' Sampling Procedures", 43 Government Accountants Journal 35 (Spring 1994).
County Ambulance Serv., Inc. v. Thompson, No. 01 CV 2320, 2002 WL 31018569, (E.D.N.Y. Sept. 11, 2002).
Georgia Department of Human Resources v. Califano, 446 F.Supp. 404 (N. D. Georgia 1977).
Illinois Physicians Union v. Miller, 675 F.2d 151, (7th Cir. 1982). Statistical sampling is allowed if it is not arbitrary, capricious or invidiously discriminatory.
Kuriansky v. Natural Mold Shoe Corp., et al, 519 N.Y.S.2d 88 (Sup. 1987).
United States ex rel. Loughren v. Unumprovident Corp., No. 03-11699-PBS, 2009 U.S. Dist. LEXIS 20320, *6 D. Mass. Feb. 24, 2009) Court concluded extrapolation is a reasonable method for determining the number of false claims so long as the statistical methodology is appropriate. The court found the plaintiff's statistical expert did not use an appropriate method and denied admission of that expert testimony.
Mercy Hospital v. New York State Department of Social Services, 79 N.Y.2d 197 (1992).
Mich. Dep't. of Educ. v. U.S. Dep't. of Educ., 875 F.2d 1196, 1204-06 (6th Cir.1989. Court approved the use of a random sampling technique used to support a determination of misused federal funds in the Michigan vocational rehabilitation program.
Mile High Therapy Centers, Inc. v. Bowen, 735 F. Supp. 984 (D. Colo. 1988).
Mount Sinai Hospital v. Weinberger, 517 F.2d 329, modified 522 F.2d 179 (5th Cir. 1975), cert. denied 425 US 935 (1976).
Pruchniewski v. Leavitt, 2006 WL 2331071 (M. D. Florida 2006). District court upheld a statistical sample of Medicare overpayments from a sample of 30 claims. This case is not reported in F. Supp., but is reported in WestLaw.
Ratanasen v. State of California Department of Health Services, 11 F.3d 1467 (9th Cir. 1993). Court allowed use of random sample to estimate overbilling of Medi-Cal. Appeals court allowed the use of sampling and extrapolation as part of audits in connection with Medicare, provided the aggrieved party has an opportunity to rebut such evidence.
Webb v. Shalala, 49 F. Supp. 2d 1114 (W. D. Ark. 1999). Court approved use of sampling in Medicare overpayment case.
Yorktown Medical Laboratory, Inc. v. Perales, 948 F.2d 84 (2nd Cir. 1991).
False Claims Act and Qui Tam ("whistleblower claims")
Qui Tam ("He who sues on behalf of the king as well as for himself") is a provision of the Federal Civil False Claims Act (FCA) that allows a private citizen to file a suit in the name of the U.S. Government charging fraud by government contractors and other entities who receive or use government funds, and share in any money recovered. Cases filed under the FCA, 31 US Code sections 3729 ff, often involve sampling from large files of Medicare or other types of claims. Some of these cases deal with whether statistical evidence is sufficient for proving liability for different types of claims.
See also www.willyancey.com/statistical_evidence.htm#Toxic_Tort
Hilao v. Estate of Marcos, 103 F.3d 767 (9th Cir. 1996). Court allowed sampling in the civil suit against former President Ferdinand Marcos.
United States v. Cabrera-Diaz, 106 F. Supp. 2d 234 (D. Puerto Rico, 2000). District Court approved use of a statistically valid random sample to establish liability for false Medicare claims in a ruling arising from a default judgment where defendants failed to appear.
United States v. Krizek, 111 F.3d 934 (D.C. Cir. 1997). Court approved parties' stipulation to limit review to a limited number of patients.
United States ex rel. Hockett v. Columbia/HCA, 498 F. Supp. 2d 25 (D. D.C. 2007), Court rejected relators' proposed method to estimate liability.
United States ex rel. Kusner v. Osteopathic Medical Center of Philadelphia, Civ. A. No. 88-9753, 1997 WL 666295 (E. D. Pa. October 23, 1997). Court expressed concern about the validity and reliability of the statistical methods in addition to the integrity of the data analyzed.
United States ex rel. Kevin K. T. Trim v. J. D. McKean, 31 F. Supp. 2d 1308 (W. D. Okla. 1998). Court held that results from a small sample could not be extrapolated to the population of all claims.
Behre, Kirby D., and A. Jeff Ifrah, "Use of Random Sampling to Prove Liability, Damages Subject to Challenge," Healthcare Fraud Report at 1003-04 (December 16, 1998).
Behre, Kirby D., and A. Jeff Ifrah, "Statisticians at DOJ May Overstate Case," National Law Journal B6 (col. 1) (March 29, 1999).
Boese, John T., "Civil False Claims Act: Ninth Circuit Issues Important Decision on Use of Sampling and Spoliation of Evidence", Fraud Mail Alert, published by Fried Frank, December 17, 2002. Discussion of United States ex rel. Aflatooni v. Kitsap Physicians Service, No. 01-36089, 2002 WL 31803398, (9th Cir. Dec. 16, 2002). In so ruling, the court joined two other circuits in ruling emphatically that the plaintiff in an FCA case must prove that the defendant knowingly submitted an actual false claim to the United States for payment. Merely showing a scheme to defraud, and proposing a sampling technique to prove the scheme resulted in false claims, was not sufficient.
Lauer, Katherine, and Roger S. Goldman, "It's Not That Easy: Why Extrapolation Is Inappropriate in the False Claims Act Context", (Latham & Watkins, 2001).
Salcido, Robert S., False Claims Act & The Healthcare Industry: Counseling & Litigation, Second Edition, (American Health Lawyers Association, 2008).
US Department of Justice, Office of the Deputy Attorney General, "Guidance on the Use of the False Claims Act in Civil Health Care Matters", June 3, 1998, http://www.usdoj.gov/dag/readingroom/chcm.htm
Associations and Law Firms on Qui Tam Litigation and False Claims Act
American Association for Justice ...formerly Association of Trial Lawyers of America (ATLA)
Bothwell & Harris
FederalFraud.com ...Perry & Campanelli LLP
Federal Whistleblower Litigation ...Ashcraft & Gerel LLP
Law Offices of Mark Allen Kleiman - False Claims Act references
Nolan Law Firm - False Claims Act Resources
Medicare Fraud Whistleblower Litigation ...Hughes & Nunn LLP
Qui Tam Information Center ...Bauman & Rasor Group, Inc.
Qui Tam Online Network ...association of plaintiff law firms
Taxpayers Against Fraud (TAF) ...association of plaintiff law firms and consumer advocates
Whistleblower Assistance ...Kreindler & Associates
Yahoo! Directory - Law - Qui Tam
Anonymous, "HCFA Drafts Plan to Use Statistical Sampling in Medicare Claims Review", 51 Healthcare Financial Management 10 (January 1997).
Anonymous, "Medicare Sampling Guidelines, Revision May Make Challenges Tougher", 5 Healthcare Fraud Report 179 (2001).
Busch, Rebecca S., Healthcare Fraud Auditing and Detection Guide, (Wiley, 2008).
Cohen, Arthur, and Joseph Naus, "A Representative Sampling Plan for Auditing Health Insurance Claims", 54 IMS Lecture Notes - Monograph Series 121 (2007), http://aps.arxiv.org/PS_cache/arxiv/pdf/0708/0708.0974v1.pdf [IMS is the Institute for Mathematical Statistics.]
Edwards, Don, Gail Ward-Besser, Jennifer Lasecki, Brenda Parker, Kristin Wieduwil, Fuming Wu, and Philip Moorhead, "The Minimum Sum Method: A Distribution-Free Sampling Procedure for Medicare Fraud Investigations", 4 Health Services and Outcomes Research Methodology 241 (December 2003). [Online at http://springerlink.com
Farley, Dean E., and Melinda Stegman, "Appropriate Sampling for Coding Audits: How Often and How Many Are Enough?", 5 Journal of Health Care Compliance 1, (January / February 2003), www.ingenix.com/content/attachments/JHCC-HSSjan-feb2003.pdf
Finger, Anne L., "They treated me like a criminal!", 2001(9) Medical Economics 114, (May 7, 2001), http://www.memag.com/memag/article/articleDetail.jsp?id=119350
Fowler, Janet F., James E. Foster, Lisa S. Foley, and Alan H. Kvanli, "Statistics, the Law and Government Auditors' Sampling Procedures", 43 Government Accountants Journal 35 (Spring 1994).
General Accounting Office, "Medicare Contractors: Despite Its Efforts, HCFA Cannot Assure Their Effectiveness or Integrity", GAO/HEHS 99-115, (July 1999), www.gao.gov/archive/1999/he99115.pdf
Glaser, David, "Medicare Audit? You Can Handle It", 2003(2) Medical Economics 53, (January 24, 2003), www.memag.com/memag/article/articleDetail.jsp?id=111243
Gregory, Thomas, and Mary K. Batcher, "The Margin of Error in Healthcare Billing Audits", Health Lawyers Weekly, (November 21, 2003).
Grizzle, Anna M. and Brian D. Roark, "Preparing for a Medicare Audit by a Program Safeguard Contractor", 10(8) HCAA Compliance Today 13 (August 2008) www.bassberry.com/communicationscenter/newsletters/
Grizzle, Anna M. and Brian D. Roark, "Preparing for a Medicare Audit by a Program Safeguard Contractor", Bass, Berry & Sims Health Law Update October 26, 2007 www.bassberry.com/files/upload/HCCA082008.pdf
Gustin, Diana L., "Medicare Audits - Monday Morning Quarterbacks" East Tennessee Medical News, (May 2008), www.latlaw.com/articles/medical_audits-monday_morning_quarterbacks.php
Gustin, Diana L., and Jessica Kulkarni, "Statistical Sampling and Extrapolation", Knoxville Academy of Medicine Bulletin (December 2007), www.latlaw.com/articles/statistical_sampling_and_extrapolation.php
Hammen, Cheryl, "Documentation Errors Result in Medicare Overpayment", Journal of American Health Information Management Association
Intriligator, Michael D., "Challenging the Use of Statistical Procedures in Medicare and Medicaid Overpayment Determinations: The Statistical Issues", (American Health Lawyers Association, 2003), http://www.healthlawyers.org/
Jost, Timothy S., and Sharon L. Davies, "The Empire Strikes Back: a Critique of the Backlash Against Fraud and Abuse Enforcement", 51(1) Alabama Law Review (Fall 1999)
Holland & Hart Health Care Practice Group, "Roaming the Random Range: Defending against governmental extrapolation of high dollar recoupment claims through statistical sampling in Medicare and Medicaid overpayment and fraud actions", Health Care Law Bulletin (March 2003), http://www.hollandhart.com/articles/HealthCareNews303.pdf
Holland & Hart, "Fighting Statistical Sampling in Medicare RAC Audits: Part I", Healthcare Law Blog, March 3, 2009, http://www.hollandharthealthcare.com/healthcare/2009/03/fighting-statistical-sampling-in-rac-medicare-audits-part-i-of-ii.html
Holland & Hart, "Fighting Statistical Sampling in Medicare RAC Audits: Part II", Healthcare Law Blog, March 3, 2009, http://www.hollandharthealthcare.com/healthcare/2009/03/fighting-statistical-sampling-in-medicare-rac-audits-part-ii-of-ii.html
Lamb,Steven W., William H. Svihla, and Jeffrey S. Harper, "The Use Of Statistical Sampling And A Single-Point Estimator To Establish Punitive Fines In Compliance Auditing: A Cautionary Note", 7 Journal of Business & Economics Research 53 (January 2009). http://www.cluteinstitute-onlinejournals.com/PDFs/1556.pdf. Reviews sampling in compliance audits of health claims and sales and use tax. Recommends use of lower bound.
Kvanli, Alan H., Janet Fowler, James E. Foster, "Warning! Some Misleading Statistical Sampling Formulas," 41 The Government Accountants Journal 49 (Winter 1992).
MacIntosh, Randall, "Review of Sampling and Extrapolation Methodologies, Early and Periodic Screening, Diagnosis and Treatment Claims Audits", Prepared for California Department of Mental Health, Medi-Cal, Epidemiology, and Forecasting Unit, (October 2006), Archived by California Legislative Analyst's Office (LAO) at http://www.lao.ca.gov/sections/health/agency_reports_06-07/EPSDT.pdf
Perling, Lester J., "Statistical Sampling in Medicare and Medicaid Overpayment Cases: A Defense Worth Pursuing", Dennis Barry's Reimbursement Advisor, (Aspen Publishing, August, 2000).
Perling, Lester J., Medicare Claims Appeals Process Handbook, (Wolters Kluwer / Aspen Publishers, 2009).
Perling, Lester J., and Annette G. Barreau, "Using Statistical Sammpling to Challenge Medicare Overpayments and Assess Compliance Efforts, in John E. Steiner, Jr., Editor, Monitoring & Auditing Practices For Effective Compliance, First Edition, (Health Care Compliance Association, 2002).
Perling, Lester J., and Michael D. Intriligator, Statistical Sampling in the Medicare Program: Challenging its Use, (American Health Lawyers Association, 2001), http://www.healthlawyers.org/
Preston, Susan Harrington, "When Medicare says, 'Let's see your records' ", 76 Medical Economics 142, (October 25, 1999), http://www.memag.com/memag/article/articleDetail.jsp?id=124720
Prophet, Sue, "Fraud and Abuse Implications for the HIM Professional" , 68(4) Journal of American Health Information Management Association 52 (1997)
Romano, Donald H., "Self-discovered Overpayments: Do I Have to Give the Money Back?", Journal of Health Care Compliance 5 (September â€“ October 2009), www.arentfox.com/email/romano/JHCC_05-09_Romano.pdf
Schweitzer, Laura, Jessica Pollner, and Jorge Sirgo, "Choosing Among Estimators", 3(5) Compliance Today 10 (May 2001).
Sirgo, Jorge, Jessica Pollner, and Laura Schweitzer, "Evaluating RAT-STATS Statistical Sampling Software", 2(9) Today's Corporate Compliance 8 (September 2000).
Sirgo, Jorge, Jessica Pollner, and Laura Schweitzer, "Achieving Meaningful Audit Results Despite Insufficient Sample Size", 10(17) Report on Medicare Compliance 4 (May 17, 2001).
Skwara, Steven E., "Statistical Sampling in Health Care Fraud Litigation", BCBSA National Internal Audit & Anti-Fraud Conference, May 2008, www.ebglaw.com/files/22326_Statistical%20Sampling%20Article%20_2_.pdf. Related article published in NHCAA Journal for Health Care Fraud Prevention, March 2007
Sreckovich, Catherine, Alan Peterson and B. Bo Martin, "Keeping the Health Care Sampling Gains Going", in John E. Steiner, Jr., Editor, Monitoring & Auditing Practices For Effective Compliance, Second Edition, (Health Care Compliance Association, 2008). www.hcca-info.org
Vanderbeek, Hank, "What Compliance Professionals Should Know about OIG Audits", Journal of Health Care Compliance, (May-June 2001), www.irpsys.com/articles/hv_audit.htm
Vanderbeek, Hank, Guide to Compliance Auditing: Applying OIG Techniques and Tools, (Opus Communications, a subsidiary of HCPro Corp., 2002), [Chapter 6 discusses Office of Inspector General's statistical estimation techniques.]
Coding Reference Sources
Clinical Classifications Software for ICD-9-CM ...Agency for Healthcare Research and Quality
Current Procedure Terminology (CPT) ...American Medical Association
Diagnosis Related Groups (DRGs) for Hospital Inpatient Procedures ... Centers for Medicare & Medicaid Services. [Medical and surgical DRGs are organized into 25 Major Diagnostic Categories (MDCs). The DRGs coordinate with the CPT codes developed by the American Medical Assocation. Medicare uses them in determining payments under the Prospective Payment System (PPS).]
Health Care Common Procedure Coding System (HCPCS) ...Centers for Medicare & Medicaid Services.
Level I of the HCPCS is comprised of CPT-4, a numeric coding system maintained by the American Medical Association.
Level II of the HCPCS is a standardized coding system that is used primarily to identify products, supplies, and services not included in the CPT-4 codes.
Level III of the HCPCS is the subsystem of codes that have been developed by Medicaid State agencies, Medicare contractors, and private insurers for use in their specific programs or local areas of jurisdiction.
International Classification of Diseases (ICD)Conversion Tables for Mental Disorders ...National Insitutes of Health Library
International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) - diagnosis codes ...US Department of Health and Human Services, Centers for Disease Control
International Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) - procedures codes ...US Department of Health and Human Services, Centers for Medicare & Medicaid Services
International Classification of Diseases (ICD), 10th Revision, Procedure Coding System (ICD-10-PCS) ...US Department of Health and Human Services, Centers for Medicare & Medicaid Services
Free searches on coding databases
AMA complimentary search on CPT codes
e-MDs complimentary search on ICD codes
ICD9Data.com ...ICD-9 and HCPCS codes
PearlDiver ...CPT codes
World Health Organization ICD-10 search online ...ICD-10 codes
National Provider Identification (NPI) Numbers (PIN)
National Plan and Provider Enumeration System (NPPES) ...maintained by Fox Systems, Inc. under contract to CMS
NPI Validator ...NPI Boost Technologies
Coding Consulting Services, Billing Software, and Training
American Hospital Association (AHA) Online Store
Beacon Healthcare Solutions
Board of Advanced Medical Coding (BAMC)
CBIZ Medical Coding Services
Chart-Tech, Inc.
JustCoding.com ...affiliated with HCPro
MedeTrac
Medical-Coding.net ...affiliated with Provistas, Inc
MedicareGuru
Provistas, Inc.
Consultants and Associations on Medicare, Medicaid, and Health Care Bill Auditing
These consultants, associations, and software vendors advise providers, insurers, employers, insureds, or healthcare administrators on claims processing and overpayment reviews. This includes Medicare, Medicaid, other government supported health programs, commercial insurance, and self-insured plans. Inclusion or exclusion on the list below is not a comment on the quality or reputation of the organization.
Contractors to US Department of Health and Human Services are listed at OSDBU Active Contracts
ACS-Heritage Information Systems
Analytic Healthcare Consulting, LLC
AmeriChoice ...subsidiary of United Health Group
Audit Quality Inc.
Avisis Health
Booz Allen Hamilton - Healthcare
Catalano and Finch Compliance Advisors
Catalyst Technologies, Inc.
Center for Medicare Advocacy, Inc. ...represents individuals in appeals of Medicare denials
CCS Holdings, L. P.
Claims Services Resource Group, Inc. ...acquired by Perot Systems
Concentra ...merged into Viant, Inc. and then into MultiPlan, Inc.
Deloitte Center for Health Solutions ...Deloitte & Touche USA LLP
Ellis Medical Consulting, Inc.
Founding Medical Informatics ...acquired by MedAssurant
FRAUDExchange, LLC
GMCF ...formerly Georgia Medical Care Foundation
Government Data Services (GDS)
Hannibal Professional Services, LLC
Health Data Management, Inc.
Health Integrity, LLC ...affiliated with Delmarva Foundation
Healthcare Billing Solutions, LLC (HBS)
Healthcare Management Solutions, LLC (HMS)
Healthways, Inc. ...formerly American Healthways
HLTH Corporation ...merged with WebMD.com
Ingenix ...subsidiary of United Health Group
IPRO, Inc. ...Island Peer Review Organization
Lewin Group ...acquired by Ingenix
Medical Audit Defense
Medical Audit Recovery Services (MARS)
Medical Billing Advocates of America (MBAA)
Medical Cost Remedy, Inc. (MCR)
Medstat ...acquired by Thomson Healthcare
MMC 20/20 Consultants
National Medicare Recovery Service (NMRS)
New York State Health Accountability Foundation (NYS HAF)
ODIS, LLC
OptumHealth ...subsidiary of United Health Group
OverpaymentAudits.com ...Liles Parker
PerSalus ...affiliate of Health Research Corporation (HRC)
Physician Reimbursement Network
PricewaterhouseCoopers Healthcare
Primax Recoveries
ProfitMark - Healthcare Solutions ...merged with Health Data Insights
Prospective Payment Specialists (PPS) ...Chargemaster
Public Consulting Group - PCG Health
QBA Consulting Corporation
Quality Health Foundation (QHF) ...affiliated with Delmarva Foundation
Specialized Medical Investigations, Inc.
StrategicHealthSolutions, LLS
The Lewin Group ...acquired by Ingenix
Thomson Healthcare ...formerly Medstat
Viant, Inc. ...acquired by MultiPlan, Inc.
Health Law Directories and Associations
American Health Lawyers Association (AHLA) ...formed from merger of National Health Lawyers Association (NHLA) and the American Academy of Healthcare Attorneys (AAHA)
AHLA links to health law web sites
Find Law: Health Law
Legal Information Institute: Health Law
Law Firms with a practice area in Health Law
Hundreds of law firms have health law practice groups. Only a few of those firms are listed below.
Joyce, Thrasher and Kaiser, LLC
Kelly Law Firm, P. C.
OverpaymentAudits.com
Wachler & Associates, P. C.
AISHealth...Atlantic Information Services, Inc.
High Risk Areas for Medicare Billing
American Medical Association Press - Online Catalog
American Statistical Association - Health Policy Statistics Section
Internal Operations Audit Manual for Health Care Facilities
Journal of Healthcare Compliance
BNA - Health Care Products
Decision Health ...a unit of UCG
EDImis ...medical billing and electronic claims software
Health Care Auditing Weekly
Health Care Compliance Congress
Health Care Fraud Blog ...Robert D. Malove
InsideHealthPolicy.com ...Inside Washington Publishers
MPMSoft ...medical billing software
PearlDiver ...Medicare patient database
Piper Report on Healthcare ...Kip Piper
Healthcare Informatics for Fraud, Waste and Abuse Protection