November 3, 2009 Feature

Medicare Begins Audits of Claims

Audiologists and speech-language pathologists who serve Medicare patients—especially those in hospital clinics—in Medicare regions C (South) and D (West) may be audited for improper payments on health care service claims.

After a three-year demonstration project, Medicare Recovery Audit Contractors (RACs) are beginning audits this fall. The RAC demonstration program, created by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, was designed to locate and correct improper fee-for-service Medicare payments to health care providers. Errors in the more than 1.2 billion Medicare claims submitted by health care providers—including hospitals and skilled nursing facilities—can account for billions of dollars in improper payments each year.

Nearly $440 million has been collected from health care providers and suppliers in the demonstration project since it began in 2005.

In audits of interest to SLPs in Regions C and D, claims paid on or after Oct. 1, 2007, will be screened in an automated process to detect if "untimed" procedure codes were billed more than once per day for an individual patient. The usual codes for evaluation and treatment of speech-language and dysphagia disorders are untimed, meaning that the code represents a session, regardless of the session length.

RACs are free to examine most outpatient settings, including physician practices; however, hospital clinics will be the main focus. The Centers for Medicare and Medicaid Services has determined that hospitals have been lax in establishing edits to identify faulty claims and have not trained practitioners adequately in coding.

States in which audits will be conducted initially will be limited to Alabama, Florida, Georgia, South Carolina, Arizona, Montana, North Dakota, South Dakota, Utah, and Wyoming. Additional information on the audits can be found on the CMS Web site.

Audiologists also should be ready for RAC audits; in the demonstration project, RACs recovered $1.4 million for overpayment of vestibular function testing in Florida. The RACs receive 9%–12.5% of payment errors they find.

Audiologists and SLPs should review their documentation and coding policies and refer to ASHA’s coding resources, guidelines, and policy statements for assistance in preparing claims. Comprehensive resources, including Medicare coding rules for audiology and speech-language pathology services, are available on the ASHA's Medicare coverage Web site.

Mark Kander, director of health care regulatory analysis, can be reached at or 301-296-5669.

cite as: Kander, M. (2009, November 03). Medicare Begins Audits of Claims. The ASHA Leader.


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