New auditor to target Medicare, Medicaid claims
WASHINGTON – A new auditor that’s in the works has the potential to streamline the process, but it will likely mean more activity, as well, industry stakeholders say.
“Anytime there’s a new contractor, they tend to be more active,” said Wayne van Halem, president of the Atlanta-based van Halem Group.
CMS this month announced plans to create a new program integrity contractor for Medicare and Medicaid called a Unified Program Integrity Contractor (UPIC). The agency plans to fold the existing ZPICs and the Medicaid program integrity contractors into the UPICs.
A likely result of the shake-up will be an increase in audits for Medicaid, stakeholders say.
“This is a little worrisome, since right now, everyone just has to deal with Medicare audits,” said Kelly Wolfe, president of Regency Billing and Consulting. “Plus, every state has different rules for Medicaid, and I don’t know how the UPIC is going to deal with that. The last thing we need is people who don’t interpret the rules the right way.”
Still, the UPICs could be a positive development for the industry, stakeholders say. The new auditor will rely on predictive modeling, data mining, software algorithms and analytic tools. It will also have the ability to better collaborate and share information among payers and other contractors. This preemptive, unified approach could mean a more streamlined process and fewer duplicate requests, they say.
That would be a real benefit for providers, says Sylvia Toscano, owner of Professional Medical Administrators.
“We are currently experiencing duplicate requests from RACs, SMRCs, MACs, and ZPIC and CERT contractors on claims already reviewed,” she said.
Stakeholders don’t expect the UPICs to be on the scene anytime soon. Awarding million-dollar contracts takes time, they say.
“ZPICs were announced four or five years ago, and they’re still not transitioned in every jurisdiction,” van Halem said.