Medicare Auditors Caught Double-Dipping

by  Edward Roche, PhD JD
Mar 14th, 2022

Overlapping extrapolations require providers to pay twice.

Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount of recoupment demanded. Providers have to pay twice.

The healthcare provider in this case is a well-established operation that has been helping patients for years. In 2017, it was audited by Recovery Audit Contractor (RAC) No. 1 (we will keep the names anonymous). In this audit, it chose to investigate claims filed across two years.

The Medicare Program Integrity Manual (PIM) provides some guidance for audits, and specifies that if the audit period is longer than a single year, then more than one audit should be conducted. But let’s set aside that problem for the time being. In this case, the audit period covered 2014 to 2016.

It is difficult to know exactly how the audit was done, because the RAC, as can be typical, failed to document its work. We know that it skipped some crucial steps in its methodology. Nevertheless, it did come up with a giant recoupment demand, as would be expected.

The provider then began its march through the Medicare appeals process. It is now 2022, and this audit finally is coming up for review by an Administrative Law Judge (ALJ). It is eight years after the claims were filed, and six years after the audit was concluded. As we know, this type of delay is characteristic of the system.

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This article originally published on January 26, 2022 by RACmonitor.