Audits: ‘It’s not fair, but it’s the reality’

ATLANTA – The government has gotten much better at analyzing data for evidence of fraud, so HME providers need to be sure they are maintaining a culture of compliance. 

That was a main takeaway during “Understanding How the Government Uses Audits to Bring Fraud Investigations” at Medtrade on Monday. 

“(The Center for Program Integrity) is currently tracking all claims,” said Josh Skora, a partner with the law firm K&L Gates. “Once they have aberrant patterns or outliers, expect them to look under the hood often.” 

The government contracts with private companies, UPICs, to perform fraud, waste and abuse auditing. 

Unfortunately for providers, they’ve gotten more aggressive in recent years, says Stephen Bittinger, a partner with K&L Gates. 

“The truth is, UPICs get paid based off the demand they turn into CMS, so they try to create the largest number they can right out of the gate,” he said. 

It’s not just the government, either. Private companies are also analyzing data looking for fraud to build whistleblower lawsuits under the False Claims Act. 

“We’ve seen a lot more whistleblowers go after competitors,” said. “If there is any semblance of truth or a strand to be pulled on, they do it. It’s not fair, but it’s the reality.” 

One area that suppliers can count on to be audited in the near future: potential fraud related to the public health emergency. 

“(With the waivers in place during the PHE), providers can put in a narrative or use modifiers,” said Bittinger. “It’s those modifiers that are going to be targeted. There will be suppliers who took advantage of the modifiers and put out equipment that wasn’t medically necessary.”