Medicare and Medicaid Audit Sampling Strategies

Developing Sampling Plans and Challenging Flawed CMS Audit Samples

Recording of a 90-minute CLE webinar with Q&A


Conducted on Tuesday, August 14, 2012

Recorded event now available

or call 1-800-926-7926
Program Materials

This CLE webinar will prepare counsel to healthcare providers to meet the demands of Medicare and Medicaid compliance audits and overpayment investigations. The panel will review the sampling process and outline approaches for providers and their counsel to challenge overpayment extrapolations.

Description

Medicare Zone Program Integrity Contractors (ZPICS) f/k/a Program Safeguard Contractors (PSCs) and Medicaid Fraud Control Units sample and analyze claims, extrapolate overpayments, and identify fraud to return the money to the Medicare Trust Fund. In many cases, auditors uncover poor documentation to support claims and not only deny the claims but use the sample results to support the application of an extrapolated overpayment.

Because of the significant dollar amounts at stake, providers facing an extrapolated overpayment should analyze the sampling methodology and determine the defenses available for challenging the statistical work. If the extrapolation is invalidated, the healthcare provider may be required to repay only the amount determined from the sample of claims examined, instead of the entire extrapolated overpayment. For the provider, this could mean paying back several thousand dollars instead of several million dollars.

Listen as our authoritative panel of healthcare attorneys and statistics experts examine Medicare and Medicaid audit sampling and extrapolation and outline ways to mount an appeal on behalf of the healthcare provider charged with receiving overpayments on claims.

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Outline

  1. Medicare fraud and the government’s use of for-profit auditors
  2. Designing and implementing sampling and extrapolation plans
    1. Purpose of sampling
    2. Key terminology
    3. Sample size
    4. Stratification
    5. How the overpayment is extrapolated
  3. The appeals process and discovery
  4. Strategies to contest overpayment extrapolations
    1. Detecting flaws in the audit method
    2. Challenging improper samples
    3. Challenge procedural fairness requirements
    4. Raising sampling issues in the appeals process

Benefits

The panel will review these and other key questions:

  • What is the legal basis for challenging the use of statistical sampling and extrapolation?
  • What are the proactive steps the healthcare provider can take to ensure there is sufficient data to mount a defense against the extrapolation?
  • What types of data sampling flaws and procedural fairness issues support an effective challenge to CMS audit samples?
  • What are the key considerations for healthcare providers in working with counsel to defend against an audit finding overpayments?

Following the speaker presentations, you'll have an opportunity to get answers to your specific questions during the interactive Q&A.

Faculty

Grizzle, Anna
Anna M. Grizzle

Member
Bass Berry & Sims

Ms. Grizzle focuses her practice on representing healthcare providers and companies in operational and compliance...  |  Read More

Maykuth, Patricia
Dr. Patricia L. Maykuth, Ph.D
President
Research Design Associates

Dr. Maykuth is a statistical expert with particular skill in experimental design, statistical sampling and...  |  Read More

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