Sampling for Medicare and Other Claims
Bibliography compiled by
Will Yancey, PhD, CPA
6848 Midcrest Drive
Dallas, Texas 75254-7944
Phone 972.387.8558
Fax 972.934.2813
Email: will@willyancey.com
Web: www.willyancey.com
Dr. Yancey has testified as an independent expert on sampling and projection of Medicare claims and other health insurance claims.
Includes audits of processing of claims,
such as Medicare, Medicaid, state-sponsored health care plans, group health care claims,
other high-volume insurance claims, and government programs.
Disclaimer: Inclusion in this list does not
imply the reference is or was a reliable authority or relevant to any
particular set of facts. Omission from this list does not imply
the item was not reliable. Links to consultants does not imply
endorsement.
Maintained by Will Yancey.
Please e-mail your suggestions for additions and changes to will@willyancey.com
Sections of this page:
Related Web pages:
Statutory Authority related to sampling Medicare or Medicaid claims
Full text of the U. S. Code is at
http://www.law.cornell.edu/uscode/ or
http://www.findlaw.com/casecode/uscodes/
Congressional bills and committee reports are at
http://thomas.loc.gov/
- 42 U.S.C. 1395ddd, "Medicare Integrity Program", subsections (a) through(e), added by Section 202(b) of the P.L. 104-191, Health Insurance
Portability and Accountability Act (HIPPA) of 1996. DHHS authorized to promote the integrity of the Medicare program by entering into contracts.
The contractors may review for Medicare overpayments.
- 42 U.S.C. 1395ddd, subsection (f), "Recovery of Overpayments" added by
Section 935 of the P.L. 108-173, Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Title IX.
Conference Committee House Report 108-391, filed November 21, 2003. DHHS
required to specify procedures for Medicare overpayment recovery audits. DHHS must develop a standard methodology for selection
of sample claims for abnormal billing patterns. The statute provides general
guidance on the use of a "statistically valid random sample" (SVRS).
- 42 U.S.C. 1395ff, subsection (d), "Deadline for Hearings by the Secretary" added by
P.L. 106-554 Consolidated Appropriations Act 2001, H.R. 5661 Benefits Improvement and Protection Act (BIPA) of 2000,
Section 521 Revisions to Medicare Appeals Process. (d)(1)(A) "... an administrative law judge shall conduct and conclude
a hearing on a decision of a qualified independent contractor under subsection (c) and render a decision on such hearing
by not later than the end of the 90-day period beginning on the date a request for hearing has been timely filed."
- 42 U.S.C. 1874A, subsection (h), "Conduct of Prepayment Review", added by
Section 934 of the P.L. 108-173, Medicare Prescription
Drug, Improvement, and Modernization Act of
2003, Title IX. Conference Committee House Report 108-391, filed
November 21, 2003. DHHS required to develop guidelines on use of
random and non-random prepayment reviews.
- Section 306, "Demonstration Project for Use of Recovery Audit
Contractors" of P.L. 108-173, Medicare Prescription
Drug, Improvement, and Modernization Act (MMA) of
2003, Title III. DHHS authorized to begin demonstration project
using recovery audit contractors under the Medicare Integrity Program
in identifying underpayments and overpayments and recouping
overpayments.
- Section 941, "Policy Development Regarding Evaluation and
Management (E&M) Documentation Guidelines" of P.L. 108-173,
Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of
2003, Title IX. DHHS authorized to develop projects and
guidelines on documentation of claims.
- Erroneous Payments Recovery Act of 2001, H.R.
2547, Added to P. L. 107-107, H.R. 2586, National Defense
Authorization Act for Fiscal Year 2002, Title VIII, Subtitle B, Sections 811-819.
Requires recovery audit programs for federal government agencies with contracts greater than $500 million
per fiscal year.
- Improper Payments Information Act of 2002, H. R. 4878, P. L. 107-300.
Requires each agency, for each program or activity with estimated
improper payments exceeding $10 million, to provide with the estimate a
report on agency actions to reduce such improper payments, including:
(1) a discussion of the causes of the improper payments and results of
the actions taken to address those causes; (2) a statement of whether
the agency has the information systems and other infrastructure it
needs to reduce such payments to minimal cost-effective levels and, if
not, a description of the resources the agency has requested to obtain
necessary systems and infrastructure; and (3) a description of the
steps the agency has taken to ensure that managers are held accountable
for reducing improper payments.
Administrative Authority - US Department of Health and Human
Services
The Centers for Medicare and Medicaid Services (CMS) was formerly known as
the Health Care Financing Administration (HCFA). HCFA was renamed CMS in June 2001.
Most of the guidance on sampling is included in Manuals or Program Transmittals.
Program Transmittals are at www.cms.hhs.gov/Transmittals/
Program Manuals are at www.cms.hhs.gov/Manuals/
Acronyms at the CMS Acronym Finder and Glossary
Assistant Secretary for Legislation
- Testimony on Medicare and Medicaid Fraud by Penny Thompson, Program Integrity Director,
Health Care Financing Administration before the House Budget Committee Health Care Task Force, July 12, 2000,
www.hhs.gov/asl/testify/t000712b.html
Health Care Financing Administration (HCFA) Program Manuals, issued and revised prior to June 2001
- Publication 13, Medicare Intermediary Manual, Part 2, Chapter VII, section
2690, Sampling Guidelines for Admissions Pattern Monitoring
- Publication 13, Medicare Intermediary Manual, Part 3, Chapter V, sections
3434.4 to 3434.6, Sampling Guidelines for Intermediaries
- Publication 14, Medicare Carrier Manual, Part 3 - Claims Process, Part 3 Table of Contents
- Part 3, Chapter VII, "Payment and Post Payment Procedures, Chapter VII Table of Contents
- The Chapter VII Appendix on Sampling Guidelines was issued
in 1975. The Sampling Guidelines were superseded by Program Memorandum
Transmittal B-01-01, issued on January 8, 2001.
- Publication 45, State Medicaid Manual, Part 07 - Quality Control, Part 07 Table of Contents
- Part 07 - Sections 7100 to 7124. Describes how sampling is used in
the Medicaid Eligibility Quality Control (MEQC) system to validate
eligibility of the total caseload and determine the dollar value of errors.
- Part 07 - Sections 7125 to 7154. Describes more details of the
sampling methods and documentation.
- Part 07 - Appendix A. Contains glossary of terms, sampling
methods, error rate calculation, and lower limit of confidence interval.
- Publication 100-6, Medicare Financial Management Manual, Chapter 3 - Overpayments
- Section 50. Referral to the Department of Justice - (Rev. 3, 08-30-02), A2-2228
Section 50. Subsection B - Paragraph 3(c). Documentation of
Referred Overpayments - Overpayments Resulting from Excessive Utilization.
Where overpayments as a result of excessive utilization are discovered, the
fiscal intermediary (FI) shall provide documentation including all
communications,relative to the development of the sample, explanation of the
techniques used, projected statistical sample results, and medical review;
provider's acceptance of the sampling techniques and the resulting overpayment
determination; and other documents.
- Publication 100-6, Medicare Financial Management Manual, Chapter 9 - Intermediary Procedures for Provider Audit
- Section 60.4.2 Evidence - (Rev. 9, 08-30-02), A4-4112.4 ...Subsection B.
1.(e). Discusses sample planning, selecting a sampling approach, and sampling risk.
- Publication 100-8, Medicare Program Integrity Manual (PIM), PIM Table of Contents
- Chapter 3, Section 6, Postpayment Review of Claims for MR Purposes.
Describes overpayment review procedures.
- Chapter 3, Section 7, Sampling Exhibits. Presents examples of sampling notification
letter, sample selection procedures, and other aspects of sampling.
- Chapter 3, Section 8, Overpayment Procedures. Describes procedures
for projecting overpayments from a Statistically Valid Random Sample (SVRS).
CMS Program Manuals issued after June 2001
Program Manuals in zipped or PDF format are online at www.cms.hhs.gov/Manuals/
Publications numbered less than 100 are in the Paper Based Manual (PBM) section.
Publications numbered 100 are in the Internet-Only Manual (IOM) section.
- Publication 45, State Medicaid Manual,
- Publication 100-04, Medicare Claims Processing Manual
- Publication 100-06, Medicare Financial Management Manual
- Publication 100-08, Medicare Program Integrity Manual
- Publication 100-13, Medicare Intermediary Manual
- Publication 100-14, Medicare Carriers Manual
Program Transmittals
The Program Transmittals related to sampling are revisions to Medicare Manuals.
Program Transmittals are online at www.cms.hhs.gov/Transmittals/
Selected HCFA and CMS Rulings are posted at http://www.cms.hhs.gov/Rulings/CMSR/list.asp
- HCFA Ruling 86-1, "HCFAR Use of Statistical Sampling to Project Overpayments to
Providers and Suppliers", effective February 20, 1986. Reviews existing law and
finds authority to use statistical sampling to project an overpayment is consistent with
common law, Medicare statute, and Department regulations. Sampling does
not deprive a provider of due process. A case-by-case review is not
required to determine the amount of overpayment. [After HCFA changed to CMS this
ruling can be cited as CMS Ruling 86-1 or CMSR 86-1. Cited in Transmittal B-03-022, March 21, 2003,
www.cms.hhs.gov/transmittals/downloads/B03022.pdf,
"Use of Statistical Sampling for Overpayment Estimation When Performing
Administrative Reviews of Part B Claims".]
- Transmittal AB-00-72, August 7, 2000, www.cms.hhs.gov/transmittals/downloads/AB0072.pdf,
"Medical Review Progressive Corrective Action (PCA)".
Provides general guidance on conducting medical reviews and estimating provider
error rates. Discusses the use of "probe reviews" with small samples to determine if further investigation is needed.
- Transmittal B-01-01, January 8, 2001, www.cms.hhs.gov/transmittals/downloads/B0101.pdf,
"Use of Statistical Sampling for Overpayment Estimation When Performing
Administrative Reviews of Part B Claims".
- Transmittal B-02-007, February 7, 2002, www.cms.hhs.gov/transmittals/downloads/B02007.pdf,
"Use of Statistical Sampling for Overpayment Estimation When Performing
Administrative Reviews of Part B Claims". Reissue of Transmittal B-01-01 with
extension of discard date to February 9, 2003.
- Transmittal B-03-022, March 21, 2003, www.cms.hhs.gov/transmittals/downloads/B03022.pdf,
"Use of Statistical Sampling for Overpayment Estimation When Performing
Administrative Reviews of Part B Claims". Reissue of Transmittal B-01-01
with extension of discard date to March 20, 2004.
- Transmittal 60, November 26, 2004, www.cms.hhs.gov/transmittals/Downloads/R60FM.pdf,
"Revised instructions on contractor procedures for provider audit and the Provider Statistical & Reimbursement Report (PSRR)".
- Transmittal 108, April 29, 2005, www.cms.hhs.gov/transmittals/downloads/R108PI.pdf "Change in Statistical Sampling Instructions".
Effective date December 8, 2004. Implements Medicare Modernization Act (MMA) section 935 (a).
- Transmittal 114, June 10, 2005, www.cms.hhs.gov/transmittals/downloads/R114PI.pdf "Change in Statistical Sampling Instructions".
Minor revision of Transmittal 108.
- Transmittal 123, September 23, 2005, www.cms.hhs.gov/transmittals/downloads/R123PI.pdf "Change Request 3703".
After Medicare administrative contractors have identified overpayment problems with providers, they may request a limited sample of documentation of subsequent claims
to test whether the problem has been resolved. For a provider specific problem the sample may be random or stratified and consist of 20 to 40 claims. For systemic problems
with multiple providers the sample size should generally be 100.
- Transmittal 184, January 26, 2007, www.cms.hhs.gov/transmittals/downloads/R184PI.pdf "Change Request 5399".
This transmittal makes minor revisions in the Medicare Program Integrity Manual Chapter 3 by updating references to Medicare contractors and affiliates.
Medicare Payment Advisory Commission (MedPAC)
The Medicare Payment Advisory Commission (MedPAC) is an independent federal body established by the
Balanced Budget Act of 1997 (P.L. 105-33) to advise the U.S. Congress
on issues affecting the Medicare program. MedPAC's website
is at www.medpac.gov
Open Door Forums ...dialogues between CMS and provider community
Medicare claims processing is provided by Medicare Administrative Contractors (MAC), as authorized by Section 911 of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173).
CMS awards contracts to the MAC for specific coverage types and geographic areas.
Most MAC have contracts for several coverage types and several geographic areas.
Most MAC are or were affiliated with the 39 member companies of the Blue Cross & Blue Shield Association ("the Blues") or their contractors.
Medicare in the United States is described at http://en.wikipedia.org/wiki/Medicare_%28United_States%29
The Blue Cross & Blue Shield companies are described at http://en.wikipedia.org/wiki/Blue_cross_blue_shield
MAC Carriers make Medicare payments to providers including doctors and equipment suppliers.
MAC Fiscal Intermediaries make Medicare payments to facilities such as hospitals and nursing facilities.
Railroad Retirement Board Carriers (RRBC) administer benefits for railroad retirees.
Medicare Part A Hospital Insurance Intermediaries administer payments to hospitals, skilled nursing facilities (SNF), community mental health centers (CMHC), and other facilities.
Medicare Part A Regional Home Health Intermediaries (RHHI) administer payments to home health agencies.
Medicare Part A Rural Health Clinic Intermediaries (RHCI) administer payments to rural clinics.
Medicare Part B Medical Insurance Carriers administer payments to individual doctors, clinics, and equipment providers.
Medicare Part B Durable Medical Equipment Regional Carriers (DMERC) administers payments to medical equipment suppliers.
Medicare Part C, also known as Medicare+Choice or Medicare Advantage, provide supplements to Parts A and B.
Medicare Part D carriers provide prescription drugs, preventive screenings, and some medical tests.
- CMS Intermediary-Carrier Directory
- CMS Medicare Contractor Website Index
- AdminaStar Federal ...now part of National Government Services
- Anthem Health Plans of New Hampshire (AHPNH) ...now part of National Government Services
- Arkansas Medicare Services ...a subsidiary of Arkansas BlueCross BlueShield
- Associated Health Services (AHS) ...now part of National Government Services
- Cahaba Government Benefit Administrators ...a subsidiary of BlueCross BlueShield of Alabama
- Carefirst ...BlueCross BlueShield affiliate in Maryland, the District of Columbia and northern Virginia
- CIGNA Government Services
- Empire Medicare Services ...now part of National Government Services
- First Coast Service Options, Inc. (FCSO) ...a subsidiary of Blue Cross and Blue Shield of Florida
- Group Health, Inc. (GHI)
- HealthNow New York, Inc.
- HGSAdministrators ...part of Highmark Medicare Services
- Highmark Medicare Services ...BlueCross BlueShield affiliate in Pennsylvania and West Virginia
- Louisiana Medicare Services ...a subsidiary of BlueCross BlueShield of Louisiana
- Medicare Northwest ...Regence is the BlueCross BlueShield affiliate in Oregon, Washington, and Idaho
- Mutual Medicare ...Mutual of Omaha
- National Government Services ...the Medicare business of Wellpoint
- National Heritage Insurance Company (NHIC) ...a subsidiary of EDS Corporation
- Noridian Administrative Services, LLC ...affilated with BlueCross BlueShield of North Dakota
- Oklahoma/New Mexico Medicare Services
- Palmetto Government Benefits Administrators, LLC ...a subsidiary of BlueCross BlueShield of South Carolina
- Pinnacle Business Solutions, Inc. (PBSI) ...a subsidiary of Arkansas BlueCross BlueShield
- Regence ...BlueCross BlueShield affiliate in Oregon, Washington, Idaho, and Utah
- Riverbend Government Benefits Administrator ...a subsidiary of BlueCross BlueShield of Tennessee
- TrailBlazer Health Enterprises, LLC ...a subsidiary of BlueCross BlueShield of South Carolina
- Triple S, Inc. ...BlueCross BlueShield affiliate in Puerto Rico
- TriSpan Health Services ...BlueCross BlueShield of Mississippi
- United Government Services, LLC ...now part of National Government Services
- Veritus Medicare Services ...became Highmark Medicare Services
- Wisconsin Physicians Service Insurance Corporation (WPS)
The Recovery Audit Contractor (RAC) demonstration program was authorized by section 306 of the Medicare Prescription Drug, Improvement, and
Modernization Act of 2003 (P.L. 108-173). The program is made permanent by section 302(h) of the Tax Relief and Health Care Act of 2006 (P. L. 109-432).
RAC identify and collect Medical claims overpayments and underpayments that were not previously identified by the MAC.
By 2010, CMS plans to have 4 RACs in place. Each RAC will be responsible for identifying overpayment and underpayments in approximately ¼ of the country.
Announcements about RAC program
Contractors for RAC program
Some of these are no longer active in the RAC program.
The Program Safeguard Contractors (PSC) conduct Medicare Part A (hospitals) and Part B (phyicians and clinical services) fraud and overpayment reviews
on behalf of the Medicare Administrative Contractors (MAC).
PSC's legal authority was approved by GAO General Counsel Decision B-282777 on September 2, 1999, http://www.gao.gov/decisions/archive/282777.pdf
See the presentation Program Safeguard Contractors: The Future of Benefit Integrity by Lisa Zone, September 2002.
See the Frequently Asked Questions (FAQs) by CSC.
Medicare Part A and Part B providers have a five-step appeals process described at www.hhs.gov/omha/levels/index.html
Level 1: After the PSC initial determination, the provider can request a redetermination from a Hearing Officer of the Medicare Administrative Contractor
Level 2: After the MAC redetermination, the provider can request a reconsideration by a designated Qualified Independent Contractor (QIC)
Level 3: After the QIC reconsideration, the provider can request a hearing by an Administrative Law Judge (ALJ) of the Office of Medicare Hearings and Appeals (OMHA)
Level 4: After the ALJ hearing, the provider can request a review by the Medicare Appeals Council of the DHHS Departmental Appeals Board (DAB)
Level 5: After the DAB review, the provider can litigate in federal district court. See Litigation in Federal and State Courts
The Medicare Part C Managed Care appeals process is described at www.cms.hhs.gov/MMCAG/
All of the PSC are or were owned by, affiliated with, or contracted to Medicare administrative contractors.
Some of the companies listed below might no longer be serving as a PSC.
- AdvanceMed ...subsidiary of Computer Sciences Corporation (CSC)
- Aspen Systems Corporation ...acquired by Lockheed Martin Information Technology
- Cahaba Safeguard Administrators, LLC ...a subsidiary of BlueCross BlueShield of Alabama
- California Medical Review, Inc. (CMRI) ...became Lumetra
- Computer Sciences Corporation (CSC): Government Health Services
- DynCorp ...AdvanceMed was formed in 2001 from DynCorp's Medicare claims business
- EDS Safeguard Services and Eastern Benefit Integrity Support Center ...a subsidiary of EDS Corporation.
EDS also owns National Heritage Insurance Company (NHIC)
- Health Integrity, LLC ...affiliate of Delmarva Foundation
- IntegriGuard ...a subsidiary of Lumetra
- Lifecare Management Partners, Inc. ...located in Alexandria, Virginia
- Lumetra ...formerly CMRI
- Mutual Medicare ...owned by Mutual of Omaha
- Regence ...BlueCross BlueShield affiliate in Oregon, Washington, Idaho, and Utah
- Safeguard Services ...also known as EDS Safeguard Services and Eastern Benefit Integrity Support Center
- Safeguard Solutions, Inc. ...affiliated with Empire Medicare Services, a unit of Wellpoint
- Science Applications International Corp (SAIC): Health Care ...through subsidiaries including MEDPROTECT, LLC
- TriCenturion ...a joint venture of
BlueCross BlueShield of South Carolina and BlueCross BlueShield of Florida
- Trust Solutions LLC ...affiliated with Wisconsin Physicians Service Insurance Corporation (WPS)
- United Government Services, LLC ...now part of
National Government Services, a unit of Wellpoint
- Western Integrity Center ...managed by Delmarva Foundation under a subcontract from Computer Sciences Corporation (CSC)
Medicare Prescription Drug appeals process is described at www.cms.hhs.gov/MedPrescriptDrugApplGriev/
The Part D appeals process is similar to appeals for Medicare Part A (hospitals) and Part B (phyicians and clinical services) fraud and overpayment reviews.
The following companies are or were MEDIC prime contractors or subcontractors.
Qualified Independent Contractors (QIC)
The QIC hear second-level appeals (also known as reconsiderations) from Medicare providers who are disputing the results of the MAC redetermination.
A provider may appeal a QIC decision to an Administrative Law Judge Hearing
See the QIC Fact Sheet provided by CMS.
Administrative Law Judges (ALJ) hear appeals of Medicare overpayment reviews.
Prior to 2005 the ALJ who heard these appeals were in the Social Security Administration (SSA) Office of Hearings and Appeals (OHA),
http://www.ssa.gov/oha/.
After 2005, Medicare appeals are heard by the DHHS Office of Medicare Hearings and Appeals (OMHA), http://www.hhs.gov/omha/
The OMHA has four regional offices and each hears cases for specific regions as shown at http://www.hhs.gov/omha/about/contacts/offices.html
After the ALJ hearing, the provider may appeal to the Department of Health and Human Services (DHHS) Appeals Board
A few ALJ decisions on sampling and extrapolation issues in Medicare overpayment reviews are cited below.
Copies of ALJ decisions may be available after the names and identifying information of beneficiaries have been redacted.
- MK Diabetic Support Services and RespiFlow, Inc., Consolidated Case Docket No. 000-47-3975, (Decision October 15, 1998, ALJ Robert S. Habermann).
Held the overpayment sampling methodology used by the carrier was invalid.
- Morrow Skin Clinic and David M. Morrow, MD,. Inc., (Decision December 20, 1994, ALJ Kenneth E. Stewart).
Held the carrier's overpayment extrapolation methodology was invalid.
- Stuart Guttman, MD, (Decision August 15, 2005, ALJ Jon D. Boltz).
Held that a sample of 15 beneficiaries is not a statistically valid sample under the Medicare standards or generally accepted statistical sampling methods.
- Total Renal Laboratories, (Decision September 21, 2004, ALJ Ronald T. Osborn).
Held the sampling estimation method used by the carrier was invalid. Carrier could
collect only the specific overpayments identified and could not extrapolate to the population.
Selected Medicare appeals decisions are posted by the Department of Health and
Human Servcies (DHHS) Departmental Appeals Board (DAB) at http://www.hhs.gov/dab/macdecision/
Some DAB rulings are searchable at http://www.hhs.gov/dab/search.html
Selected HCFA and CMS Rulings are posted at http://www.cms.hhs.gov/Rulings/CMSR/list.asp
Selected rulings related to statistical sampling and projection are cited below.
- HCFA Ruling 86-1, "HCFAR Use of Statistical Sampling to Project Overpayments to
Providers and Suppliers", effective February 20, 1986. Reviews existing law and
finds authority to use statistical sampling to project an overpayment is consistent with
common law, Medicare statute, and Department regulations. Sampling does
not deprive a provider of due process. A case-by-case review is not
required to determine the amount of overpayment. [After HCFA changed to CMS this
ruling can be cited as CMS Ruling 86-1 or CMSR 86-1. Cited in Transmittal B-03-022, March 21, 2003,
www.cms.hhs.gov/transmittals/downloads/B03022.pdf,
"Use of Statistical Sampling for Overpayment Estimation When Performing
Administrative Reviews of Part B Claims".
- Departmental Appeals Board, Grant Appeals Board, Tennessee Department of Health and
Environment, DAB No. 898, (September 11, 1987), http://www.hhs.gov/dab/decisions/dab898.txt
- Departmental Appeals Board, Civil Remedies Division, Keith O. Irby and Michelle P. Irby, R. Ph.,
Docket C-243, Decision No. CR321 (July 13, 1994), http://www.hhs.gov/dab/decisions/cr-321.htm
- Departmental Appeals Board, Medicare Appeals Council, Samuel Nigro, MD, (April 30,
2001) http://www.hhs.gov/dab/macdecision/Nigro.html
- Departmental Appeals Board, Medicare Appeals Council, Metro Home Care,
(December 17, 2001) http://www.hhs.gov/dab/macdecision/metrohomecare.html
- Departmental Appeals Board, Medicare Appeals Council, Vascular Diagnostic Center and Vascular Testing Center, (April 17, 2003) at http://www.hhs.gov/dab/macdecision/vascdiagcntr.html
The PRRB is an independent panel to which a certified Medicare provider of
services may appeal if it is dissatisfied with a final determination of its fiscal
intermediary or the appeal to CMS.
- PRRB Home Page
- PRRB Decisions
- AllCare Home Health, Inc. (Denver, Colorado), PRRB Decision No. 2000-D9 (December 9, 1999),
www.cms.hhs.gov/PRRBReview/downloads/2000D9.pdf.
Intermediary adjusted a provider's owner compensation based on the Michigan compensation survey data. Provider's
expert challenged the study's small sample size and low response rate. The PRRB ruled the Michigan compensation
survey was not valid for this particular provider.
- Hospital San Fransisco, Inc. (Rio Pedras, Puerto Rico), PRRB Decsion No. 2003-D57 (September 12, 2003),
www.cms.hhs.gov/PRRBReview/downloads/2003D57.pdf.
Intermediary denied a hospital's bad debt adjustment based on a sample of 9 patients out of a 1,099 patient population.
The PRRB ruled the sample size was too small, and adjusted the result to only those 9 patients rather than allowing
a projection to the population.
- Chaves County Home Health Service, Inc. v. Sullivan, 931 F.2d 914 (DC Cir. 1991),
cert. denied 502 US 1091, 112 S.Ct. 1160(1992).
- Chaves County Home Health Service, Inc. v. Sullivan, 723 F.Supp 188 (D. C. District 1990).
- See discussion of Chaves case in Fowler, Janet F., James E. Foster, Lisa S. Foley, and Alan H. Kvanli,
"Statistics, the Law and Government Auditors' Sampling Procedures", 43 Government
Accountants Journal 35 (Spring 1994).
- County Ambulance Serv., Inc. v. Thompson,
No. 01 CV 2320, 2002 WL 31018569, (E.D.N.Y. Sept. 11, 2002).
- Georgia Department of Human Resources v. Califano, 446
F.Supp. 404 (N. D. Georgia 1977).
- Illinois Physicians Union v. Miller, 675 F.2d 151,
(7th Cir. 1982).
- Kuriansky v. Natural Mold Shoe Corp., et al, 519
N.Y.S.2d 88 (Sup. 1987).
- Mercy Hospital v. New York State Department of Social
Services , 79 N.Y.2d 197 (1992).
- Mile High Therapy Centers, Inc. v. Bowen, 735 F. Supp.
984 (D. Colo. 1988).
- Mount Sinai Hospital v. Weinberger, 517 F.2d 329,
modified 522 F.2d 179 (5th Cir. 1975), cert. denied 425 US 935 (1976).
- Ratanasen v. State of California Department of Health Services, 11 F.3d 1467 (9th Cir. 1993). Court allowed use of random sample to
estimate overbilling of Medi-Cal.
- Webb v. Shalala, 49 F. Supp. 2d 1114 (W. D. Ark. 1999).
- Yorktown Medical Laboratory, Inc. v. Perales, 948 F.2d 84 (2nd Cir. 1991).
Qui Tam ("He who sues on behalf of the king as well as for himself") is a provision of the Federal Civil False Claims Act (FCA)
that allows a private citizen to file a suit in the name of the U.S. Government charging fraud by government contractors
and other entities who receive or use government funds, and share in any money recovered.
Cases filed under the FCA,
31 US Code sections 3729 ff, often involve sampling from large
files of Medicare or other types of claims. Some of these cases
deal with whether statistical evidence is sufficient for proving
liability for different types of claims.
See also www.willyancey.com/statistical_evidence.htm#Toxic_Tort
Cases
- Hilao v. Estate of Marcos, 103 F.3d 767 (9th Cir. 1996). Court
allowed sampling in the civil suit against former President Ferdinand Marcos.
- United States v. Cabrera-Diaz, 106 F. Supp. 2d 234 (D.
Puerto Rico, 2000). District Court approved use of a statistically
valid random sample to establish liability for false Medicare claims in a ruling
arising from a default judgment where defendants failed to appear.
- United States v. Krizek, 111 F.3d 934 (D.C. Cir. 1997). Court approved parties' stipulation
to limit review to a limited number of patients.
- United States ex rel. Hockett v. Columbia/HCA, 498 F. Supp. 2d 25 (D. D.C. 2007),
Court rejected relators' proposed method to estimate liability.
- United States ex rel. Kusner v. Osteopathic Medical Center of
Philadelphia, Civ. A. No. 88-9753, 1997 WL 666295 (E. D. Pa.
October 23, 1997). Court expressed concern about the validity and
reliability of the statistical methods in addition to the integrity of
the data analyzed.
- United States ex rel. Kevin K. T. Trim v. J. D. McKean, 31 F. Supp. 2d 1308
(W. D. Okla. 1998). Court held that results from a small sample
could not be extrapolated to the population of all claims.
Articles and Guides
- Behre, Kirby D., and A. Jeff Ifrah, "Use of Random Sampling to
Prove Liability, Damages Subject to Challenge," Healthcare Fraud
Report at 1003-04 (December 16, 1998).
- Behre, Kirby D., and A. Jeff Ifrah, "Statisticians at DOJ May
Overstate Case," National Law Journal B6 (col. 1) (March 29,
1999).
- Boese, John T., "Civil False Claims Act: Ninth Circuit Issues Important
Decision on Use of Sampling and Spoliation of Evidence", Fraud Mail Alert,
published by Fried Frank, December 17, 2002. Discussion of United States ex rel. Aflatooni v.
Kitsap Physicians Service, No. 01-36089, 2002 WL 31803398, (9th Cir. Dec. 16, 2002).
In so ruling, the court joined two other circuits in ruling emphatically that the plaintiff in an FCA case must
prove that the defendant knowingly submitted an actual false claim to the United States for payment.
Merely showing a scheme to defraud, and proposing a sampling technique to prove the scheme resulted in false claims,
was not sufficient.
- Lauer, Katherine, and Roger S. Goldman, "It's Not That Easy: Why
Extrapolation Is Inappropriate in the False Claims Act Context",
(Latham & Watkins, 2001).
- Salcido, Robert S., False Claims Act & The Healthcare Industry: Counseling & Litigation, Second Edition,
(American Health Lawyers Association, 2008).
- US Department of Justice, Office of the Deputy Attorney General,
"Guidance on the Use of the False Claims Act in Civil Health Care Matters",
June 3, 1998, http://www.usdoj.gov/dag/readingroom/chcm.htm
Associations and Law Firms on Qui Tam Litigation and False Claims Act
- Anonymous, "HCFA Drafts Plan to Use Statistical Sampling in
Medicare Claims Review", 51 Healthcare Financial Management 10 (January 1997).
- Anonymous, "Medicare Sampling Guidelines, Revision May Make Challenges Tougher", 5 Healthcare Fraud Report 179 (2001).
- Busch, Rebecca S., Healthcare Fraud Auditing and Detection Guide, (Wiley, 2008).
- Cohen, Arthur, and Joseph Naus, "A Representative Sampling Plan for Auditing Health Insurance Claims", 54 IMS Lecture Notes - Monograph Series
121 (2007), http://aps.arxiv.org/PS_cache/arxiv/pdf/0708/0708.0974v1.pdf
[IMS is the Institute for Mathematical Statistics.]
- Edwards, Don, Gail Ward-Besser, Jennifer Lasecki, Brenda Parker, Kristin Wieduwil, Fuming Wu, and Philip Moorhead,
"The Minimum Sum Method: A Distribution-Free Sampling Procedure for Medicare Fraud Investigations",
4 Health Services and Outcomes Research Methodology 241 (December 2003). [Online at http://springerlink.com
- Finger, Anne L., "They treated me like a criminal!", 2001(9) Medical Economics 114, (May 7,
2001), http://www.memag.com/memag/article/articleDetail.jsp?id=119350
- Fowler, Janet F., James E. Foster, Lisa S. Foley, and
Alan H. Kvanli, "Statistics, the Law and Government Auditors' Sampling
Procedures", 43 Government Accountants Journal 35 (Spring 1994).
- General Accounting Office, "Medicare Contractors: Despite Its Efforts, HCFA Cannot Assure Their Effectiveness or Integrity", GAO/HEHS 99-115, (July 1999),
www.gao.gov/archive/1999/he99115.pdf
- Glaser, David, "Medicare Audit? You Can Handle It", 2003(2) Medical Economics 53, (January 24,
2003), www.memag.com/memag/article/articleDetail.jsp?id=111243
- Gregory, Thomas, and Mary K. Batcher, "The Margin of Error in Healthcare Billing Audits", Health Lawyers Weekly, (November 21, 2003).
- Hammen, Cheryl, "Documentation Errors Result in Medicare
Overpayment", Journal of American Health Information Management
Association, republished at http://www.claimtrust.com/overpay.htm
- Intriligator, Michael D., "Challenging
the Use of Statistical Procedures in Medicare and Medicaid Overpayment
Determinations: The Statistical Issues", (American Health Lawyers Association, 2003),
http://www.healthlawyers.org/
- Jost, Timothy S., and Sharon L. Davies, "The Empire Strikes Back:
a Critique of the Backlash Against Fraud and Abuse Enforcement", 51(1) Alabama Law Review (Fall 1999), http://www.law.ua.edu/lawreview/jostdavies.htm
- Holland & Hart Health Care Practice Group, "Roaming the Random Range: Defending against governmental extrapolation
of high dollar recoupment claims through statistical sampling in Medicare and Medicaid overpayment and fraud actions",
Health Care Law Bulletin (March 2003),
http://www.hollandhart.com/articles/HealthCareNews303.pdf
- Kvanli, Alan H., Janet Fowler, James E. Foster, "Warning! Some Misleading Statistical Sampling Formulas," 41 The Government
Accountants Journal 49 (Winter 1992).
- MacIntosh, Randall, "Reivew of Sampling and Extrapolation Methodologies, Early and Periodic Screening, Diagnosis and Treatment
Claims Audits", Prepared for California Department of Mental Health, Medi-Cal, Epidemiology, and Forecasting Unit, (October 2006),
Archived by California Legislative Analyst's Office (LAO) at
http://www.lao.ca.gov/sections/health/agency_reports_06-07/EPSDT.pdf
- Perling, Lester J., "Statistical Sampling in Medicare and Medicaid Overpayment Cases: A Defense Worth Pursuing",
Dennis Barry's Reimbursement Advisor, (Aspen Publishing, August, 2000).
- Perling, Lester J., and Michael D. Intriligator, Statistical
Sampling in the Medicare Program: Challenging its Use, (American
Health Lawyers Association, 2001), http://www.healthlawyers.org/
- Preston, Susan Harrington, "When Medicare says, 'Let's see your
records' ", 76 Medical Economics 142, (October 25, 1999), http://www.memag.com/memag/article/articleDetail.jsp?id=124720
- Prophet, Sue, "Fraud and Abuse Implications for the HIM
Professional", 68(4) Journal of American Health Information Management Association 52 (1997), http://www.ahima.org/infocenter/payersguide/journal.97.4.cfm
- Schweitzer, Laura, Jessica Pollner, and Jorge Sirgo,
"Choosing Among Estimators", 3(5) Compliance Today 10 (May 2001).
- Sirgo, Jorge, Jessica Pollner, and Laura Schweitzer,
"Evaluating RAT-STATS Statistical Sampling Software", 2(9) Today's Corporate Compliance 8 (September 2000).
- Sirgo, Jorge, Jessica Pollner, and Laura Schweitzer,
"Achieving Meaningful Audit Results Despite Insufficient Sample Size", 10(17) Report
on Medicare Compliance 4 (May 17, 2001).
- Vanderbeek, Hank, "What Compliance Professionals Should Know
about OIG Audits", Journal of Health Care Compliance, (May-June 2001), http://www.irpsys.com/articles/hv_audit.htm
- Vanderbeek, Hank, Guide to
Compliance Auditing: Applying OIG Techniques and Tools, (Opus
Communications, a subsidiary of HCPro Corp., 2002), http://www.hcmarketplace.com/Prod.cfm?id=843&source=EHCAW
[Chapter 6 discusses Office of Inspector General's statistical
estimation techniques.]
Coding Health Care Claims
Coding Reference Sources
- Clinical Classifications Software for ICD-9-CM ...Agency for Healthcare Research and Quality
- Current Procedure Terminology (CPT) ...American Medical Association
- Diagnosis Related Groups (DRGs) for Hospital Inpatient Procedures ... Centers for Medicare & Medicaid Services.
[Medical and surgical DRGs are organized into 25 Major Diagnostic
Categories (MDCs). The DRGs coordinate with the CPT codes
developed by the American Medical Assocation. Medicare uses them
in determining payments under the Prospective Payment System (PPS).]
- Health Care Common Procedure Coding System (HCPCS)
...Centers for Medicare & Medicaid Services.
- Level I of the HCPCS is comprised of CPT-4, a numeric coding
system maintained by the American Medical Association.
- Level II of the HCPCS is a standardized coding system that is
used primarily to identify products, supplies, and services not
included in the CPT-4 codes.
- Level III of the HCPCS is the subsystem of codes that have been
developed by Medicaid State agencies, Medicare contractors, and private
insurers for use in their specific programs or local areas of
jurisdiction.
- International
Classification of Diseases (ICD)Conversion Tables for Mental Disorders ...National Insitutes of Health Library
- International
Classification of Diseases (ICD), 9th Revision, Clinical Modification
(ICD-9-CM) - diagnosis codes ...US Department of Health and Human Services, Centers for Disease Control
- International
Classification of Diseases (ICD), 9th Revision, Clinical Modification (ICD-9-CM) - procedures codes
...US Department of Health and Human Services, Centers for Medicare & Medicaid Services
- International Classification of Diseases (ICD), 10th Revision, Procedure Coding System (ICD-10-PCS)
...US Department of Health and Human Services, Centers for Medicare & Medicaid Services
- National Uniform Claim Committee (NUCC)
Free searches on coding databases
Coding Consulting Services, Software, and Training
Consultants and Associations on Medicare, Medicaid, and Health Care Bill Auditing
These consultants, associations, and software vendors advise providers, insurers, employers, insureds, or healthcare administrators on claims processing and
overpayment reviews. This includes Medicare, Medicaid, other government supported health programs, commercial insurance, and self-insured plans.
Inclusion or exclusion on the list below is not a comment on the quality or reputation of the organization.
- AccessMED
- ACS Healthcare
- ACS-Heritage Information Systems
- AdvanceMed ...subsidiary of Computer Sciences Corporation (CSC)
- Advanta Medical Solutions, LLC
- Analytic Healthcare Consulting, LLC
- American Health Quality Association (AHQA)
- Association of Healthcare Internal Auditors (AHIA)
- Audit Quality Inc.
- Austin Provider Solutions
- Avisis Health
- Bland & Associates
- Booz Allen Hamilton - Healthcare
- Catalyst Technologies, Inc.
- Center for Medicare Advocacy, Inc. ...represents individuals in appeals of Medicare denials
- CDR Associates
- CCS Holdings, L. P.
- Claims Management, Inc.
- Claim Technologies Incorporated
- Claims Services Resource Group, Inc. ...acquired by Perot Systems
- Coding Compliance Solutions
- Coding & Reimbursement Network (CRN)
- Concentra
- Connolly Consulting Associates, Inc.
- Coordinated Payment Technologies, Inc.
- Connolly Consulting Associates, Inc.
- Delmarva Foundation
- Deloitte Center for Health Solutions ...Deloitte & Touche USA LLP
- DiversiMed, Inc.
- Dixon Hughes PLLC
- DST Health Solutions
- enVision Group, Inc.
- Essential Edge
- Exscribe, Inc.
- Fairpay Solutions
- Feeley & Driscoll, P.C.
- Founding Medical Informatics ...acquired by MedAssurant
- GMCF ...formerly Georgia Medical Care Foundation
- Government Data Services (GDS)
- Healthcare Information Xchange of New York (HIXNY)
- HealthDataInsights, Inc.
- Health Decisions, Inc.
- Health Grades, Inc.
- Health Integrity, LLC ...affiliated with Delmarva Foundation
- Health Management Associates
- Health Management Systems
- Health Research Corporation (HRC)
- Health Research Insights, Inc. ...affiliate of Health Research Corporation (HRC)
- Healthcare Data Management, Inc.
- Healthcare Management Solutions, LLC (HMS)
- Healthways, Inc. ...formerly American Healthways
- HLTH Corporation
- Hooper Cornell Healthcare
- Hospital Bill Auditing ...Edward R. Waxman & Associates
- Huron Consulting Group
- Ingenix
- IPRO, Inc. ...Island Peer Review Organization
- KPMG
- Laguna Medical Systems
- Livanta LLC
- Managed Care Planning Associates, Inc. (MCPA)
- MANN Health Care Recovery
- ManagedCare.com
- McKesson Health Solutions, LLC
- MedAssurant
- Medical Audit Recovery Services (MARS)
- Medical Billing Advocates of America (MBAA)
- Medical Compliance Associates
- Medical Cost Remedy, Inc. (MCR)
- Medicare Quality Improvement Community (MedQIC)
- MediCo Unlimited
- MediTract
- Medstat ...acquired by Thomson Healthcare
- National Committee for Quality Assurance (NCQA)
- National Health Care Anti-fraud Association (NHCAA)
- National Healthcareer Association (NHA)
- National Medicare Recovery Service (NMRS)
- Navigant Consulting, Inc.
- New York State Health Accountability Foundation (NYS HAF)
- ODIS, LLC
- Parente Randolph
- Patient Advocate Foundation (PAF)
- Permedion
- Perot Systems
- PerSalus ...affiliate of Health Research Corporation (HRC)
- Per-Se Technologies, Inc.
- PRG-Schultz
- PricewaterhouseCoopers Healthcare
- Primax Recoveries
- ProfitMark - Healthcare Solutions
- Public Consulting Group (PCG)
- Q Mark, Inc.
- QBA Consulting Corporation
- Quality Health Foundation (QHF) ...affiliated with Delmarva Foundation
- Rising Medical Solutions, Inc.
- Ross Health Actuarial
- Sagebrush Solutions
- Specialized Medical Investigations, Inc.
- Stokeld & Company ...prescription drug purchase audits
- StrategicHealthSolutions, LLS
- Symphony Corporation
- The Kramer Group
- The Lewin Group ...acquired by Ingenix
- Thomson Healthcare ...formerly Medstat
- TierMed Systems, LLC
- UHY Advisors
Law Firms Representing Providers in Medicare Overpayment Disputes
Hundreds of law firms have a practice area in health care law. Links to a few of these firms and directories are provided below.
Health Law Directories and Associations
Law Firms with a practice area in Health Law
- Akin Gump
- Arent Fox
- Bennett Bigelow & Leedom
- Broad and Cassel
- Dean Mead
- Epstein Becker & Green
- Dean Mead
- Foley & Lardner LLP
- Fox Rothschild
- Fredrikson & Byron, P. A.
- Gallagher & Kennedy
- Hall, Render, Killian, Heath & Lyman, P.C.
- Holland & Hart
- Hooper, Lundy & Bookman
- Jones Day
- Joyce, Thrasher and Kaiser, LLC
- Kelly Law Firm, P. C.
- King & Spalding
- Latham & Watkins
- Liles Parker
- London & Amburn
- McDermott Will & Emery
- Patton Boggs
- Poyner & Spruill
- Ropes & Gray
- Sonnenschein Nath & Rosenthal
- Wachler & Associates, P. C.
- Waller Lansden Dortch & Davis, LLP
Publishers, Associations, and Conference Organizers
Maintained by Will Yancey. Please
e-mail any comments or suggestions to will@willyancey.com