Oncology practices are facing an alarming surge in audits and scrutiny from government and private payors. Medicare, managed care entities, and commercial insurance companies have significantly ramped up their auditing practices in this space. This aggressive audit approach often results in substantial overpayment demands against providers, even for well-established oncology groups, based on seemingly minor documentation deficiencies, coding discrepancies, or credentialing issues.
Overpayment demands pose severe financial and legal risks that can undermine a practice’s operational stability and reputation. Payors’ widespread use of extrapolation compounds the threat by turning a relatively small number of findings into exorbitant overpayment demands that span from hundreds of thousands to millions of dollars.
Several services have attracted intense payor focus in oncology audits over the past few years:
- Anti-Emetic Medications: Auditors frequently target the use of anti-nausea medication during chemotherapy administration. Payors often require documentation of signs of intolerance or a patient history of intolerance per Medicare’s requirements. Inadequate documentation can result in repeated denials, subjecting a practice to heightened scrutiny and further audits.
- Hydration Services: Payors may automatically deny hydration charges without explicit documentation confirming patient dehydration. Additionally, many payors have deemed hydration solely for therapy administration as “incidental” and not separately billable.
- Vitamin B12 Injections: Records must clearly document a patient’s B12 deficiency through progress notes and lab results to substantiate B12 injections. Consistent failure to thoroughly document this deficiency prompts blanket denials and increased scrutiny from payors.
While these services are widely accepted as standards of care in oncology, payors are quick to deem them “not medically necessary” without adequate documentation substantiation.
- Modifiers JW and JZ: Recently, CMS introduced modifier JZ, which providers must use to attest that there was zero wastage from a single-dose drug vial, in addition to the continued use of modifier JW when there is discarded drug waste. CMS will deny claims for single-dose vials without these modifiers and has increased its review of documentation and policies surrounding the selection of appropriate vials.
- Evaluation & Management (E/M) Services: Routinely billing office visit codes with modifier 25 in conjunction with chemotherapy administration, without documentation supporting a visit where a full reassessment was required, is under heightened scrutiny. Auditors often target inappropriate use of modifier 25.
- Documentation of Chemotherapy Drug Administration: Payors require meticulous and detailed documentation regarding all aspects of chemotherapy administration, including drug invoices, names of administering staff, lot numbers, and more. Lapses in this information can create easy targets for overpayment demands.
Consistently failed audits can expose providers and their practices to serious potential repercussions, including an extrapolated overpayment demand, exclusion from the Medicare Program, civil monetary penalties, suspension of Medicare payments, revocation of Medicare billing privileges, de-credentialing, litigation under the False Claims Act, or, in the most severe cases, a criminal referral.
Providers must remain informed and proactive in their approach to billing, audits, and overpayment demands to avoid these serious legal and financial implications. Early intervention provides the best path for providers to effectively contest or mitigate overpayment demands while safeguarding their practice.
How Frier Levitt Can Help
Frier Levitt employs a comprehensive and multi-faceted strategy to effectively challenge unfavorable audit findings or demands for overpayment. Our attorneys work closely with vetted certified professional coders who possess invaluable knowledge in oncology coding, and who provide invaluable expertise in understanding the clinical nuances and documentation complexities specific to oncology coding.
While our extensive experience handling payor audits and collaborative relationships with the legal and special investigation departments of major payors is an asset to our clients, practices that have retained our services at the onset of an audit tend to benefit the most. It is invaluable to retain legal counsel at the onset of an audit when the initial document demand is made. Contact Frier Levitt attorneys immediately if your practice receives a document demand, notice of pre-payment review, or overpayment demand. Additionally, call to arrange a consultation for assistance with audit defense with one of our experienced healthcare attorneys.
