Purpose of a PPS Audit Tool

Beginning in 2005, the Centers for Medicare and Medicaid Services (CMS), empowered by Congress, began the requirement of evidence-based Medicare claims from medical and health-care providers. The purpose of this initiative was to eliminate Medicare fraud and its drain on the U.S. budget.



Medical and health-care providers must ensure that their operations are in compliance with CMS guidelines and regulations. Therefore, it is important for providers to perform self-audits using tools and templates that forces the auditors to look at all aspects and functions that fall under CMS rules.

The Audit Environment

• Several CMS special-purpose audit teams now exist, including Recovery Audit Contractors (RACs), Health Care Fraud Prevention and Enforcement Teams (HEAT), Medicare Recovery Contractors (MACs), Medicaid Integrity Contractors (MICs) and Zone Program Integrity Contractors (Z-PICs). RAC auditors are seeking to recover improper payments in the past. MAC auditors concentrate on current claims. The HEAT is to investigate fraud in health care. The other teams (MICs and Z-PICs) ensure proper procedures and documentation are in use.

Medicare PPS

• To motivate medical and health-care professionals to provide patient care as efficiently and effectively as possible, Medicare extends prospective payment systems (PPS). PPS grew out of the health maintenance organization (HMO) movement of the 1980s, in which patients (members) pay a flat premium that covers all care they may need. The PPS program pays the HMO a single payment to cover a Medicare patient for a fixed period of future care or for an entire hospital stay.

  PPS fraud involves Medicare billing from providers for PPS services not provided, deceased patients and even fictitious patients, among several other deceptive and fraudulent billings. To eliminate these actions and many others is the purpose behind the Medicare audit and investigative teams.

Audit Tools

• CMS makes several general and specific health-care practice checklists, guidelines and even software that can be downloaded for use. For example, in the home health-care area, a segment of the health-care market that uses Medicare PPS heavily, CMS provides a wide variety of how-tos, regulation summaries, case studies and training resources for its Outcome and Assessment Information Set (OASIS), which is the primary PPS reporting format.

  In addition, several consulting firms, software houses and medical services cooperatives have a variety of packages that a medical facility can use to implement its compliance program. However, any medical practice that simply follows the rules has little or no need for these services. This is not to say that there are medical practices or facilities that can forgo all self-audit tools. Medicare laws and rules change frequently and compliance can become a challenge.

The Purpose of the Audit Tools

• The purpose behind the use of Medicare PPS audit tools is for a medical facility to self-verify that its operations are in compliance with CMS rules, regulations and guidelines prior to an audit visit from a RAC or MAC or one of the other compliance inspection and enforcement teams.

  There is no set format or required content for Medicare PPS audit tools. Each facility or practice may devise its own set of audit (compliance) tools, use those provided by CMS or purchase tools or hire a consultant. In any case, medical and health-care providers need to assure not only themselves, but the government as well, that they are in compliance and not submitting fraudulent billings.