New legislation introduced to help reduce Medicare audits

The Audit Improvement and Reform Act (AIR Act), H.R. 5083 was introduced into the House of Representatives. Sponsored by Rep. Renee Ellmers and Rep. John Barrow, the Audit Improvement and Reform (AIR) Act will increase transparency, education and outreach and reward suppliers who have low error rates on audited claims.

The AIR Act will apply to all MACs, RACs and all other contractors performing audits on Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) providers. Key provisions in the legislation include:

  • Restore clinical inference and clinical judgment when evaluating audits, which will significantly reduce error rates;
  • Require the reporting of error rates on audited claims after adjustment for those audited claims that have been overturned on appeal;
  • Require each audit contractor to establish an education and outreach program that would help providers better understand the regulations and how to document medical necessity for Medicare patients;
  • Allow the Department of Health and Human Services to ensure that all suppliers are audited at least once every 2 years and those with low error rates can be excused from some or all audits during that 2-year period. DMEPOS suppliers with a 15% or below audited claims error rate will be subject to 1 claim audit a year;
  • Require Medicare contractor transparency and reporting;
  • Limit documentation review periods to 3 years for all Medicare audits;
  • For reoccurring claims, the Secretary shall toll the timely claim filing limits so DMEPOS supplier are not prohibited from taking an appeal from the determination of a claim in a prepayment or postpayment audit, or the submission or resubmission for payment of any claims that follow sequentially from the audited claim on the basis that the timely claim filing limits have expired;
  • The Secretary shall not implement policy changes or clarifications for DMEPOS audit requirements sooner than 6 months after publishing the changes in the Federal Register.

“Thousands of small businesses across the country are facing complex and unnecessary burdens just so they can get compensated for the medical equipment they are providing for our seniors. This is happening because of an excessive auditing system enforced by the Department of Health and Human Services,” Ellmers stated in a statement. “The current auditing process has important merits and was put in place because of the fraud and abuse that exists within the Medicare system. But instead of targeting illegal practices and bad actors, HHS is instead choosing to focus on people who are playing by the rules and providing jobs for millions of hardworking Americans. At the same time, third-party contractors are profiting over these excessive audits and being used by HHS to halt payments to providers for as many as 3 years.”

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