Challenging and Managing Medicare Audits, Denials, and Appeals

Anecdotal evidence from O&P professionals indicates that audits and denials from Medicare contractors are again on the rise, creating burdens that challenge the viability of some O&P practices or, at the very least, place a strain on cash flow and divert resources away from patient care.

The Centers for Medicare & Medicaid Services (CMS) has every right to reopen claims that have already been paid to try to ensure that Medicare contractors are processing claims correctly and that providers are providing medically necessary care. However, in many instances, the aggressive tactics of some Medicare contractors pushes the boundaries of program integrity and begin to look more akin to harassment and veiled attempts to recoup funds CMS is not rightly owed. The fact that Recovery Audit Contractors (RACs) are financially incentivized to deny claims contributes to provider skepticism about Medicare’s program integrity efforts. Reports from the field suggest the problem is again getting worse, as some contractors seem to largely disregard Medicare rules and regulations in denying O&P claims.