Medicare Audit

IPSIS: Formerly the Spine Intervention Society
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SSdoc33 said:
i am sure that the bureaucrats are quaking in their boots when 10khertz calls them unethical.....
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They would if we had more active societies defending our interests. Maybe you should be more active at the governmental level , and troll the SDN forums less…
 
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Unification belt.
 
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10KHertz said:
Steve what’s your take on hyperaggressive OIG audits ? Seems like tremendous over reach .
They provide no real explanation when attempting payment retractions .
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It's the government. It's not personal. Just got audited for my 2020 taxes. Asked for 1098 as well as statement for January and December of that year. My accountant says he has never heard of this. Sending in paperwork. It's why we need smaller government. Trillions in waste.
 
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lobelsteve said:
It's the government. It's not personal. Just got audited for my 2020 taxes. Asked for 1098 as well as statement for January and December of that year. My accountant says he has never heard of this. Sending in paperwork. It's why we need smaller government. Trillions in waste.
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The IRS targets conservative groups and individuals , it’s still wrong. OIG is no different in the medical realm. Good luck on the audit.
 
The irs targets people who do their taxes conservatively? i dont get what you are saying
 
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Ducttape said:
and amazing how people choose to remember only certain aspects of the past...

www.npr.org

As IRS Targeted Tea Party Groups, It Went After Progressives Too

After three years of congressional hearings and three inspector-general audits, the scandal still ricochets around Capitol Hill.
www.npr.org www.npr.org
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IRS lost many suits to conservative groups in court (real data). Show me the equivalent of officially settled and lost IRS cases against liberals. But then again, I didn’t care to change your political world view .
www.reuters.com

Justice Department settles with conservative groups over IRS scrutiny

The U.S. Justice Department has reached a settlement with dozens of conservative groups that claimed the Internal Revenue Service unfairly scrutinized them based on their political leanings when they sought a tax-exempt status, court documents showed.
www.reuters.com www.reuters.com
 
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lobelsteve said:
It's the government. It's not personal. Just got audited for my 2020 taxes. Asked for 1098 as well as statement for January and December of that year. My accountant says he has never heard of this. Sending in paperwork. It's why we need smaller government. Trillions in waste.
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Its weird that they would target an individual-- unless your accountant is getting 'creative'. I dont know your finances, but keep a close eye on the accountant.
 
the watch dog agency found that progressive groups were also targetted.

but Jeff Sessions, the trump attorney general, chose to settle only with conservatives. go figure. of course, its not politics...

fyi,
Republicans claimed the targeting of conservative groups showed political bias in the IRS under former Democratic President Barack Obama. House Republican investigators found no connection to the Obama administration, according to a 2014 report.
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10KHertz said:
IRS lost many suits to conservative groups in court (real data). Show me the equivalent of officially settled and lost IRS cases against liberals. But then again, I didn’t care to change your political world view .
www.reuters.com

Justice Department settles with conservative groups over IRS scrutiny

The U.S. Justice Department has reached a settlement with dozens of conservative groups that claimed the Internal Revenue Service unfairly scrutinized them based on their political leanings when they sought a tax-exempt status, court documents showed.
www.reuters.com www.reuters.com
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anyone can get harrassed....i.e. investigated. And the media goes bonkers piling on when conservatives get investigated, especially a previous president. They dont even cover when liberals are investigated.
 
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Ducttape said:
the watch dog agency found that progressive groups were also targetted.

but Jeff Sessions, the trump attorney general, chose to settle only with conservatives. go figure. of course, its not politics...

fyi,
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both sides target.....we get it. Now do a follow up.
 
Most good accountants know what thresholds not to surpass.
OIG seems like it’s going on a pain medicine zealous rampage .
Nobody is immune . Contest all audits (assuming you follow lcds) or you’re ruining the field long-term, IMO.
 
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It's kinda pathetic and annoying they're coming for us; especially since we're trying to not prescribe opioids. However if they keep doing what they're doing and keep decreasing reimbursement. Perhaps just running an opioid only practice will be less of a headache.
 
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buddababa said:
It's kinda pathetic and annoying they're coming for us; especially since we're trying to not prescribe opioids. However if they keep doing what they're doing and keep decreasing reimbursement. Perhaps just running an opioid only practice will be less of a headache.
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Until they decide you are a pill pusher, send you to jail and then publish the number of mcg of opioids you prescribed over a 10 year period to get a public reaction.

“In June 2022 buddababa prescribed 100000 mcg of hydrocodone showing they are a danger to society.”

And the public will be outraged, not understanding that was a 10 pill prescription for postop. Which clearly is the reason for all of the opioid overdoses. This opioid epidemic has NOTHING to do with the cartel fentanyl flooding over our border.

You should be ashamed Dr. Buddababa. Now go serve your sentence. And also… they will again get their money back.
 
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10KHertz said:
Just got my 18 patient rfa audit from 2019-2020 . OIG doesn’t specifically state what the clinical issues were. My guess is that their system flags rfa close to 6 months esp, If you perform unilateral RAfa. They flagged a thoracic and cervical rfa within 6 months , probably don’t understand the overlapping codes .

My advice is the fight everything . Tell them they are unethical scum , and are abusing their auditing power . Strike some fear in this OIG dept.

ASIPP needs to grow a pair and fight for us, or give me back my diplomat status money, LAX…
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Everything should be fought. Name calling may not be the best strategy. An attorney and third party “independent biller/coder” may be able to review and advocate/negotiate for you
 
It’s unreal they’re coming after docs as aggressively as they are considering they were in bed with Purdue Pharma and were directly complicit in the current opioid crisis we’re now all fighting. If you haven’t seen Dopesick you need to. The corruption within big pharma was no surprise. The degree of the govt’s corruption or perhaps incompetence on the other hand was quite disturbing
 
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40 charts audited, 20 clawed back, another audit starts in july to see if corrective measure have been implemented - such crap. Like all their reasonings are arbitrary. May just need to create a template from their requirements and just copy and paste on every patient. Feel like i should call out the nurse reviewer for making my life difficult.
 
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buddababa said:
40 charts audited, 20 clawed back, another audit starts in july to see if corrective measure have been implemented - such crap. Like all their reasonings are arbitrary. May just need to create a template from their requirements and just copy and paste on every patient. Feel like i should call out the nurse reviewer for making my life difficult.
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Great that you are fighting it. OIG should feel the pressure from our retaliation.
They can’t force patients to have a cervical rfa bilaterally , and limit rfa to two nebulous “sessions” per year.
Should be a “region” can be treated per 6-12 months NOT 1”session” per 6 months. Total nonsense.
 
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buddababa said:
40 charts audited, 20 clawed back, another audit starts in july to see if corrective measure have been implemented - such crap. Like all their reasonings are arbitrary. May just need to create a template from their requirements and just copy and paste on every patient. Feel like i should call out the nurse reviewer for making my life difficult.
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What was their reasoning for clawing back those 20?
 
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Sig123 said:
What was their reasoning for clawing back those 20?
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didnt document that the reason for lmbb was for workup towards rfa. also didn't specify that it was fluoro guided. (in office note), yet submitted procedure note states as such. many little things like that.
 
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buddababa said:
didnt document that the reason for lmbb was for workup towards rfa. also didn't specify that it was fluoro guided. (in office note), yet submitted procedure note states as such. many little things like that.
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WHAT!?! that is absurd !
 
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I got denied payment on several cervical and lumbar esi because I used icd 10 code m48.02 for cervical esi's ans m48.062 for lumbar esi
They denied.payment and we appealed and they reviewed and said those were not covered diagnosis codes for the esi.
So now they aren't paying..

This was new to me
I have always used those codes but apparently now this year they are not covered
 
buddababa said:
didnt document that the reason for lmbb was for workup towards rfa. also didn't specify that it was fluoro guided. (in office note), yet submitted procedure note states as such. many little things like that.
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Do you think it would be wise to contact an attorney at this point?
 
jsaul said:
I got denied payment on several cervical and lumbar esi because I used icd 10 code m48.02 for cervical esi's ans m48.062 for lumbar esi
They denied.payment and we appealed and they reviewed and said those were not covered diagnosis codes for the esi.
So now they aren't paying..

This was new to me
I have always used those codes but apparently now this year they are not covered
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Why not just change the code and resubmit the claim as a corrected claim? You should be able to get those claims paid for. Don't appeal, just resubmit with the appropriate ICD 10 code. You can't win on an appeal if their policy does not accept those codes.
 
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buddababa said:
didnt document that the reason for lmbb was for workup towards rfa. also didn't specify that it was fluoro guided. (in office note), yet submitted procedure note states as such. many little things like that.
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Is this a face to face conversation by chance?
 
Im thrilled that there is already a thread on this because this is exactly what I logged in after several months to rave about.

WTF. So let me get this straight. As of last year medicare expects us to 1) have recent imaging preferably MRI prior to performing any epidurals? 2) Patients with documented radicular pain in any way shape or form cant receive facet interventions? 3)nickel and diming on procedure note details? 3)nickel and diming on pre and post-procedural assessment? 4)dosages not reported correctly??

Is there any way to fight against these b@5tard$? They are going to suffocate us.
 
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TeslaCoil said:
Im thrilled that there is already a thread on this because this is exactly what I logged in after several months to rave about.

WTF. So let me get this straight. As of last year medicare expects us to 1) have recent imaging preferably MRI prior to performing any epidurals? 2) Patients with documented radicular pain in any way shape or form cant receive facet interventions? 3)nickel and diming on procedure note details? 3)nickel and diming on pre and post-procedural assessment? 4)dosages not reported correctly??

Is there any way to fight against these b@5tard$? They are going to suffocate us.
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Do not participate in insurance and your cost of delivering healthcare can be cut in half. Less staff, leff meaningless use. You don’t have to worry about billing or collections. You can except credit cards cash or checks.
 
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TeslaCoil said:
Im thrilled that there is already a thread on this because this is exactly what I logged in after several months to rave about.

WTF. So let me get this straight. As of last year medicare expects us to 1) have recent imaging preferably MRI prior to performing any epidurals? 2) Patients with documented radicular pain in any way shape or form cant receive facet interventions? 3)nickel and diming on procedure note details? 3)nickel and diming on pre and post-procedural assessment? 4)dosages not reported correctly??

Is there any way to fight against these b@5tard$? They are going to suffocate us.
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Check out the new crappy United HC epidural guidelines … terrible . Began nationwide today . Only the upper class will be getting pain medicine in the future
 
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What the heck are our pain societies doing not advocating for this??
 
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here's the issue...

im guessing most of us use epidurals in a manner that is scientifically and medically valid. we use them for radicular back pain most commonly in some dermatomal distribution. we use them judiciously, and with safe injection practices (give or take slight preferences).


that is not what a lot of "pain docs" are doing, and it is costing society tons of money, and resulting in tons of failed injections. and it is screwing us over.

im sure you all have seen or heard of patients who have gotten:
blind epidurals
epidurals every other week
multiple injections at multiple different sites, +/- sedation at one time
blind facet injections
"series of 3" SI injections
entire spine segment RFAs (5 levels +)
multiple bilateral transforaminals at once (the most i have seen is 10 at one time)
injections done by people not certified or qualified
stims that were for native backs with nonneuropathic symptoms
stims with leads not even reaching ligamentum flavum

i could do this all day. you get the point.
 
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Is there a Medicare requirement for how old an MRI can be to get an ESI approved? Thanks.
 
Wanna hear about underpaid? Between myself and 2 PA's I'm seeing 40-60 pts per day and performing 50-70 procedures per week. Fridays I travel 2 hours each way to one of our clinics.
MD87 said:
Is there a Medicare requirement for how old an MRI can be to get an ESI approved? Thanks.
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I dont think medicare puts a number on it but you do have to have at least some kind of imaging. Some of the others say 12 months or 2 years.... it varies.
 
so i had my Medicare review call today regarding 20 deficient procedures regarding signatures and missing documentation from 2019. She immediately saw all the signatures were there. She also saw my documentation on each procedure note regarding meds and concentrations. Regarding the LCD, i have templates which are redundant to what i document on my SOAPs and H+P, so she removed the ones we discussed(about 5) and sent the remaining 15 for re-review. Basically regarding 3 month history if facet pain, non-radicular, no stenosis, bla bla bla.

****ing waste of time. Re-review within 30 days. Hopefully they fix their mistakes.
 
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buddababa said:
40 charts audited, 20 clawed back, another audit starts in july to see if corrective measure have been implemented - such crap. Like all their reasonings are arbitrary. May just need to create a template from their requirements and just copy and paste on every patient. Feel like i should call out the nurse reviewer for making my life difficult.
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my reviewer noted i satisfied the LCD with my generic procedure note, but cautioned each patient needs to have individualized treatment, so make check marks instead.
 
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My favorite: "It appears that the information is simply from a template and not individualized from patient to patient".

Of course it's a template, you're the ones who make me document so much absolute non-relevant nonsense!


Note: My templates are accurate for each patient.
 
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Doctodd said:
my reviewer noted i satisfied the LCD with my generic procedure note, but cautioned each patient needs to have individualized treatment, so make check marks instead.
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I can’t imagine making every procedure note different. Does anyone actually do this ?
 
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Ferrismonk said:
My favorite: "It appears that the information is simply from a template and not individualized from patient to patient".

Of course it's a template, you're the ones who make me document so much absolute non-relevant nonsense!


Note: My templates are accurate for each patient.
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I don’t use emr…..I use a typed up procedure note that is the same including medication name and concentration(lidocaine 0.5%, etc)….I write in the volume or mg and my signature. I also write in other pertinent details like pain score before and after and anything else I think is important.
 
Ferrismonk said:
My favorite: "It appears that the information is simply from a template and not individualized from patient to patient".

Of course it's a template, you're the ones who make me document so much absolute non-relevant nonsense!


Note: My templates are accurate for each patient.
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Don’t Medicare and insurers deny us with templates? I wish I could say, sorry your clawback note looks to be templated and not individualized to me so I am not responsible to pay you back anything.
 
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My updated CMS MBB BS verbiage:

Patient meets CMS criteria for facet joint treatment: 1) Pain is rated NRS>6 (moderate to severe), 2) Pain > 3 months, 3) Pain has not responded to more conservative care options as documented in this note and/or the patient's original consult note, 4) Radiculopathy or neurogenic claudication, if present, has been treated, 5) There is no other known cause of the patient's axial pain (such as fracture, tumor, infection, or significant deformity), 6) Pain was assessed at baseline, and is assessed following diagnostic medial branch blocks using the same scale asking patients to rate their subjective % pain relief attributable to the procedure. 7) Notes are all signed electronically when closed using our Athena EHR system. 8) No steroid is used in any of our medial branch block procedures ever. 9) No "region" defined as cervical, thoracic, or lumbar is ever treated with RFA more than once in a six-month period. 10) Medications and concentrations are documented in procedure notes. 11) ALL facet interventions in this clinic are performed with fluoroscopic guidance, 12) Although templates are used to demonstrate that treatment conforms to CMS requirements, each patient's care is highly individualized. 13) "Function" was assessed at baseline using the Oswestry questionnaire. 14) "Confirmatory" medial branch blocks are only performed if patient reported subjective pain relief is sustained at 80% or greater for the approximate duration of action of the agent used (for bupivacaine 0.25%, this is 4-6 hours; for lidocaine 2%, this is 1-2 hours). 15) Dr. Powermd is qualified to perform the procedure consistent with CMS requirements having ABA board certification in anesthesiology with ABA subspecialty certification in pain medicine.

Anything missing?
 
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powermd said:
My updated CMS MBB BS verbiage:

Patient meets CMS criteria for facet joint treatment: 1) Pain is rated NRS>6 (moderate to severe), 2) Pain > 3 months, 3) Pain has not responded to more conservative care options as documented in this note and/or the patient's original consult note, 4) Radiculopathy or neurogenic claudication, if present, has been treated, 5) There is no other known cause of the patient's axial pain (such as fracture, tumor, infection, or significant deformity), 6) Pain was assessed at baseline, and is assessed following diagnostic medial branch blocks using the same scale asking patients to rate their subjective % pain relief attributable to the procedure. 7) Notes are all signed electronically when closed using our Athena EHR system. 8) No steroid is used in any of our medial branch block procedures ever. 9) No "region" defined as cervical, thoracic, or lumbar is ever treated with RFA more than once in a six-month period. 10) Medications and concentrations are documented in procedure notes. 11) ALL facet interventions in this clinic are performed with fluoroscopic guidance, 12) Although templates are used to demonstrate that treatment conforms to CMS requirements, each patient's care is highly individualized. 13) "Function" was assessed at baseline using the Oswestry questionnaire. 14) "Confirmatory" medial branch blocks are only performed if patient reported subjective pain relief is sustained at 80% or greater for the approximate duration of action of the agent used (for bupivacaine 0.25%, this is 4-6 hours; for lidocaine 2%, this is 1-2 hours). 15) Dr. Powermd is qualified to perform the procedure consistent with CMS requirements having ABA board certification in anesthesiology with ABA subspecialty certification in pain medicine.

Anything missing?
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Looks good. However ‘region’ is irrelevant now. CMS/ngs/ASIPP screwed us with substituting the term “sessions” in 2019. They can retract every procedure you didn’t perform bilaterally in one session , and repeated within year.

Untied HC commercial only pats for ESIs a 3 months . No exceptions.

ASIPP/CMS/my coming after sI injections soon, and possibly more rfa restrictions.

Our leaders are irrelevant…

What percentage of this forum would actually participate in a one day Pain Medicine strike nationwide to express our resentment and constrains with treating chronic pain patients ?Can’t even prescribe gabapentin without monitoring soon. Now is the time …
 
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10KHertz said:
Looks good. However ‘region’ is irrelevant now. CMS/ngs/ASIPP screwed us with substituting the term “sessions” in 2019. They can retract every procedure you didn’t perform bilaterally in one session , and repeated within year.

Untied HC commercial only pats for ESIs a 3 months . No exceptions.

ASIPP/CMS/my coming after sI injections soon, and possibly more rfa restrictions.

Our leaders are irrelevant…

What percentage of this forum would actually participate in a one day Pain Medicine strike nationwide to express our resentment and constrains with treating chronic pain patients ?Can’t even prescribe gabapentin without monitoring soon. Now is the time …
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may have to switch to cash only practice and re-use needles like they do in 3rd world countries - sad.
 
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