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Government Denials

Washington & West’s experience extends across all government payers including Medicare, which includes extensive experience with both pre- and post-payment review audits, Medicaid and TRICARE. We have a full comprehension of the various types of audits that government contractors can perform and the implications of the audit findings. From identifying the clinical evidence needed to support the services rendered, to the legal skill needed to guide the case through the multi-leveled appeals process, our team of experts has decades of combined experience navigating appeals before all Centers for Medicare & Medicaid Services (CMS) contractors. Washington & West understands how each contractor operates and what opportunities are available for any denial rendered, which makes us a vital resource for providers seeking assistance through the appeals process for government denials, including Recovery Audit Contractor (RAC) appeal services, education, or consulting.

Recovery Audit Contractor (RAC)/Medicare Administrative Contractor (MAC)

With the introduction of the RAC and MAC programs, hospitals face the demand to return alleged overpayments and the threat of denial of payment up front. MACs have the authority to review any claim at any time and can even initiate 100 percent prepayment review of claims should they determine that a hospital’s coding and billing compliance rises to the level of a “serious problem.”  Both programs were created by Congress with the intention of preserving the integrity of the Medicare trust fund.  However, the contingency fee structure under which the contractors work skews the focus of the program away from preservation by focusing solely on denying as many payments as possible, instead of educating providers in an effort to reduce denials.  The sheer volume of denials that can result from these audits can quickly overburden even the most organized of denial management teams and as such, can threaten the success of a provider appeal.

Zone Program Integrity Contractor (ZPIC)/ Office of the Inspector General (OIG)

Hospitals and healthcare systems are likely aware that the government has made healthcare fraud and abuse enforcement a top priority.  Audits by ZPICs and theOIG focus on potential fraud and abuse for all Medicare claims.  ZPICs hold the power to refer cases to law enforcement for criminal prosecution of the entity and the individuals involved.  Entities and individuals can be charged in civil litigation under the False Claims Act or face the imposition of a civil monetary penalty or other sanctions. Washington & West’s experience with OIG and ZPIC investigations has given us a distinct understanding of the issues surrounding potential fraud and when a claim should be considered for obligatory reporting.

Washington & West collects the necessary documentation from the client, which is then organized in an easy to reference fashion for the contractor’s review. After an internal review of the documentation is completed, a summary of the findings is provided to the client, explaining pertinent positive and negative information found in the documentation.  Should the claim(s) remain denied after contractor review, Washington & West will proceed through our appeals process, including the presentation to an Administrative Law Judge if required.

Comprehensive Error Rate Testing (CERT)

The Centers for Medicare & Medicaid Services (CMS) uses the CERT program to measure improper payments that are not considered fraud but which may not meet Medicare requirements.  Utilizing random sampling, the target of the CERT program are errors made by fiscal intermediaries (FIs), Medicare Administrative Contractors (MACs) or other carriers when paying providers’ Medicare claims.

While a hospital or health system may not be the specific target of a CERT, providers are affected because they are responsible for complying with medical records requests for claims being reviewed by CERT.  And, ultimately, if CERT uncovers coding or billing errors, the contractor will take action to recoup Medicare payments from the hospital.

Compliance with coding and billing rules associated with the CERT program has become increasingly challenging and time consuming.  CERT errors typically do not occur because the services were not medically necessary. Rather, CERT errors generally indicate a failure to submit documentation, or a lack of documentation to support the medical necessity.

Quality Improvement Organization (QIO)

QIOs operate as an extension of The Centers for Medicare & Medicaid Services (CMS).  The mission of QIOs is to constantly improve health care services by identifying and improving deficiencies in the quality of care provided to Medicare beneficiaries, evaluating the value of the services provided and how medically appropriate the services were in resolving the patient’s condition.  QIOs work in conjunction with all medical service providers to ensure delivery of the safest and highest quality of care.  A QIO denial can be fairly subjective and results from a beneficiary’s complaint indicating that the provider did not appear to follow best practices or meet their expected standards of care, followed by a review of the complaint to determine adherence to established guidelines and professionally recognized standards of care.


Similar to Medicare, TRICARE, utilizes regional contractors to process claims.  However, unlike Medicare, which provides five levels of appeal, the TRICARE appeals process only provides three levels of review for denied claims.  Furthermore, the type of review available varies depending on whether the denial of benefits involves a medical necessity determination, factual determination, provider authorization, provider sanction, and/or a dual-eligibility determination.

In all TRICARE appeals, the burden of proof is on the appealing party to establish by substantial evidence the appealing party’s right to payment.  With limited opportunities to make a case, providers must maximize each available opportunity.

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Towson, MD 21204
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