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As health care providers receiving reimbursement from the government for the care delivered to our patients, we are subject to potential review of our records and claims. This is to “assure integrity” for the services we provide to our patients.
 
However, recently I came across a list of agencies and organizations who can review our records and claims to “assure integrity” in the care we provide…and the list was long. Too long. Especially when viewed through the lens of providers who simply want to provide a good service and get paid an amount which reflects the skill they have acquired, expertise they have gained, and sacrifice they have made to become a health care provider.
 
Given the levels of review and potential audits that are in place to “assure integrity,” an undesirable level of complexity has been added to our health care system. This complexity deters the most skilled providers from providing care to patients who are reimbursed by the government. In addition, many providers who are clinical experts feel their livelihood is threatened when they are unable to understand and maintain a current knowledge of all the rules and processes imposed by these agencies and organizations who are “assuring integrity.”
 
As taxpayers, we may be glad that the government has put into place organizations working to assure integrity in health care for our taxpayer dollar by reviewing medical records and claims. However, is the review of medical records and claims a valid measurement for integrity of care?
 
And, as they are watching over us, who is watching over them?
 
Nine Organizations Assuring Integrity for Health Care Reimbursed by the Government…

  • Recovery Audit Contractors (RACs): Can review all providers
  • Office of the Inspector General (OIG): Publishes a work plan each fall stating the providers they will review
  • Comprehensive Error Rate Testing Contractors: Potential reviews for all providers who submit claims to Medicare
  • Medicare Payment Error Rate Measurement Contractors (PERM)
  • Hospital Payment Monitoring Program: Reviews hospital claims submitted to Medicare
  • Zone Program Integrity Contractors (ZPIC): For hospitals submitting claims to Medicare
  • Qualified Independent Contractors (QIC): For hospitals submitting claims to Medicare
  • Program Safeguard Contractors (PSC): For providers submitting claims to Medicare
  • MAC/FI/Carriers: Review providers specific to geographic region and provider type

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Bridget Morehouse PT, MBA is a consultant with Steffes and Associates, a rehabilitation consulting firm based in Wisconsin.