Logo

Log In Sign Up |  An official publication of: American College of Emergency Physicians
Navigation
  • Home
  • Multimedia
    • Podcasts
    • Videos
  • Clinical
    • Airway Managment
    • Case Reports
    • Critical Care
    • Guidelines
    • Imaging & Ultrasound
    • Pain & Palliative Care
    • Pediatrics
    • Resuscitation
    • Trauma & Injury
  • Resource Centers
    • mTBI Resource Center
  • Career
    • Practice Management
      • Benchmarking
      • Reimbursement & Coding
      • Care Team
      • Legal
      • Operations
      • Quality & Safety
    • Awards
    • Certification
    • Compensation
    • Early Career
    • Education
    • Leadership
    • Profiles
    • Retirement
    • Work-Life Balance
  • Columns
    • ACEP4U
    • Airway
    • Benchmarking
    • Brief19
    • By the Numbers
    • Coding Wizard
    • EM Cases
    • End of the Rainbow
    • Equity Equation
    • FACEPs in the Crowd
    • Forensic Facts
    • From the College
    • Images in EM
    • Kids Korner
    • Medicolegal Mind
    • Opinion
      • Break Room
      • New Spin
      • Pro-Con
    • Pearls From EM Literature
    • Policy Rx
    • Practice Changers
    • Problem Solvers
    • Residency Spotlight
    • Resident Voice
    • Skeptics’ Guide to Emergency Medicine
    • Sound Advice
    • Special OPs
    • Toxicology Q&A
    • WorldTravelERs
  • Resources
    • ACEP.org
    • ACEP Knowledge Quiz
    • Issue Archives
    • CME Now
    • Annual Scientific Assembly
      • ACEP14
      • ACEP15
      • ACEP16
      • ACEP17
      • ACEP18
      • ACEP19
    • Annals of Emergency Medicine
    • JACEP Open
    • Emergency Medicine Foundation
  • About
    • Our Mission
    • Medical Editor in Chief
    • Editorial Advisory Board
    • Awards
    • Authors
    • Article Submission
    • Contact Us
    • Advertise
    • Subscribe
    • Privacy Policy
    • Copyright Information

Medicare Audits Create More Headaches, Delays for Medical Billing

By Richard Quinn | on April 11, 2014 | 0 Comment
Features
  • Tweet
  • Email
Print-Friendly Version

Emergency physicians and hospitals increasingly frustrated with length of audit process, delayed reimbursement on successfully appealed claims

You Might Also Like
  • Medicare Cuts Payment For Psych Care in the ED
  • ED Leaders Prepare for Medicare Payment Reforms, Quality-of-Care Improvements
  • Anthem Blue Cross Starts Prepayment Review on Level 5 Emergency Department E/M Medicare Claims
Explore This Issue
ACEP Now: Vol 33 – No 04 – April 2014

Consultants and billing experts say emergency physicians and the hospitals they work in are increasingly frustrated with the growing length of the entire audit process—including getting paid back for denied claims that have successfully appealed.  

James Blakeman, senior vice president of the billing company Emergency Groups’ Office in Arcadia, Calif., said that delayed reimbursement can be damaging to hospitals, in particular, as those amounts are typically for hundreds of thousands of dollars. While individual payment denials to emergency physicians are “not usually material to a practice’s financial viability,” the implications of multiple held-up payments can be so significant physicians have no choice but to fight them, he said.

“Physicians cannot simply concede an audit if they know they are right because Medicare claims that these are all ‘educational,’” Mr. Blakeman said, adding, “You are made to feel like you have committed fraud and that someday they could say, ‘We told you before that you were billing in error, now we are opening a large audit because you acknowledged (by not contesting before) that you were coding incorrectly.’ That result could be disastrous. Injustice and fear of future audits are what haunt emergency physicians when they think about billing Medicare and Medicaid.”

Practicing emergency physician John Stimler, DO, CPC, CHC, FACEP, a founder and managing member of health care consultant Bettinger, Stimler & Associates of Pinecrest, Fla., said he hears of too many groups that don’t defend themselves. While he doesn’t approve of that, he said it is understandable given the staffing and financial burden of mounting an aggressive defense.

“A lot of groups give up because they don’t want to spend the money to do it,” said Dr. Stimler, a member of ACEP’s Reimbursement Committee. “It becomes a double-, or triple-, or quadruple-edged sword. You not only lose the money between the code choices, but you have to pay for the staff to defend yourself. All those steps are very expensive.”

The process is also time consuming. If a hospital, physician group, or solo practitioner wants to appeal a Recovery Audit Contractor decision, it has 120 days to file what is known as a “redetermination,” which is conducted by Medicare carriers or MACs. While the appeal deadline is 120 days, one can only avoid a Medicare recoupment action if the appeal is filed within 30 days. A second level of appeal is known as “reconsideration,” and is conducted by Qualified Independent Contractors (QICs). Then a case can be appealed to an administrative law judge. Above that level, appeals can be filed to the U.S. Department of Health and Human Services or a federal court.

Pages: 1 2 | Single Page

Topics: BillingCMSCost of Health CareEmergency MedicineEmergency PhysicianMedicaidMedicareMedicare AuditPublic PolicyReimbursement and Coding

Related

  • EM Runs in the Family

    February 26, 2025 - 0 Comment
  • Artificial Intelligence for Medical Billing

    October 7, 2024 - 1 Comment
  • Medicare’s Reimbursement Updates for 2024

    January 13, 2024 - 0 Comment

Current Issue

ACEP Now May 03

Read More

About the Author

Richard Quinn

Richard Quinn is an award-winning journalist with 15 years’ experience. He has worked at the Asbury Park Press in New Jersey and The Virginian-Pilot in Norfolk, Va., and currently is managing editor for a leading commercial real estate publication. His freelance work has appeared in The Jewish State, ACEP Now, The Hospitalist, The Rheumatologist, and ENT Today. He lives in New Jersey with his wife and three cats.

View this author's posts »

No Responses to “Medicare Audits Create More Headaches, Delays for Medical Billing”

Leave a Reply Cancel Reply

Your email address will not be published. Required fields are marked *


*
*

Wiley
  • Home
  • About Us
  • Contact Us
  • Privacy
  • Terms of Use
  • Advertise
  • Cookie Preferences
Copyright © 2025 by John Wiley & Sons, Inc. All rights reserved, including rights for text and data mining and training of artificial technologies or similar technologies. ISSN 2333-2603