Medicare Claims Auditor Responds to Allegations After Bill Introduced
On Friday, an auditing firm hired to review Medicare claims defended its rejection of tens of millions of dollars in reimbursements submitted by California hospitals, arguing that it is abiding by CMS regulations, the Sacramento Bee reports.
The comments by PRG-Schultz International followed legislation introduced Thursday by Reps. Lois Capps (D-Calif.) and Devin Nunes (R-Calif.) that would halt the program for one year while it undergoes review by the Government Accountability Office and Medicare administrators (Whitney, Sacramento Bee, 11/10).
Capps said she expects most of the 53 members of California's delegation in the House to sign on to the bill, adding that California representatives have been asking CMS for more information about the program in California for more than two months.
Under a contract with CMS, PRG-Schultz International reviews Medicare claims submitted by hospitals to help root out improper payments.
The auditor has rejected more than 90% of the claims submitted by California hospitals for rehabilitation services to patients with knee and hip replacements. Under its CMS contract, PRG-Schultz receives up to a 30% commission on such claims (California Healthline, 11/8).
The auditor has voluntarily agreed to forgo commissions if claims are overturned on appeal.
The program currently is being piloted in California, Florida and New York, and it is scheduled to expand nationwide on a permanent basis.
Lee White, director of U.S. operations for PRG-Shultz, said that only a small portion of rejected claims are overturned on appeal. He attributed the high rejection rate to a large number of patients receiving medically unnecessary levels of treatment.
White also noted that many of the approximately 85 rehabilitation hospitals in California have had no rejected claims.
To date, more than $230 million in Medicare overpayments have been discovered in California, according to PRG-Schultz (Sacramento Bee, 11/10).