Bass, Berry & Sims attorneys Denise Barnes and Kristin Bohl recently spoke with hfma about significant changes affecting wound care providers, including the Centers for Medicare & Medicaid Services’ (CMS) revised Medicare reimbursement methodology for skin substitutes, heightened audit activity, and the government’s increasing reliance on data analytics to identify potential fraud and abuse. Denise noted that regulators are using increasingly sophisticated tools to identify billing outliers, explaining that artificial intelligence and data analytics can help agencies detect providers that may warrant additional scrutiny.
“I’ve heard that CMS has been more aggressive in payment suspensions, using them more affirmatively. I think we can expect the use of data analytics and AI to identify what CMS views as potential practitioners, providers and hospital systems that are likely engaging in fraud,” Denise added.
The article also highlighted growing financial and operational pressures facing providers as Medicare contractors pursue audits and recoupment actions related to skin substitute claims. Kristin observed that some providers are facing “millions to tens of millions of dollars in recoupment efforts from Medicare” while simultaneously adapting their practices to comply with evolving reimbursement and coverage requirements.
In the midst of the financial pressure, Kristin said providers are “working to change their current and future practice to be compliant and figure out what products are still available and that they can use for patients.
Denise further emphasized the importance of responding quickly and comprehensively to government inquiries, noting that payment suspensions and enforcement actions can have a significant impact on healthcare organizations.
The full article, “Medicare Skin Substitute Reimbursement Changes Have Raised Provider Risks,” was published by hfma on July 13 and is available online.