March 1, 2021

Volume XI, Number 60

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March 01, 2021

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Finding and Fixing Provider-Based Criteria Problems

The Medicare provider based criteria have been around for over 10 years but still raise cause for concern. Basically on or off campus patient care locations that meet the criteria get to bill at higher hospital rates. Because the implications of not meeting the provider based rules are great (the assessment of overpayments and possible penalties as false claims), many providers hesitate to undertake audits even though the OIG consistently cites the criteria in its annual work plans. However, finding and reducing the risk associated with the criteria is very important.

The Audit Protocol was drafted in-line with the federal regulations which are open to greater interpretation than what's evident from the provider-based questionnaires published by Medicare administrative contractors. This Audit Protocol can be completed by an auditor, compliance officer or as part of a facility self-audit. We would recommend that the audit, however, be conduced under attorney-client privilege.

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Copyright © 2020, Sheppard Mullin Richter & Hampton LLP.National Law Review, Volume I, Number 92
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