How the Government Uses Data to Hunt Fraud: Audits and FCA, hosted by Medtrade West 2021

​The world of government audits is ever changing, be it Recovery Audit Contractors (RACs), Unified Program Integrity Contractors, Medicaid Integrity Contractors, or the Office of Inspector General, and providers, particularly durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) companies, must stay up-to-date on the audit trends. The focus of these audits, as well as the denial rational, are constantly moving, as providers' approach and responses to these audits must also continuously adjust.  A variety of provider types, including DMEPOS providers should be aware of a large RAC audit, which ended in 2019, concerning specific drug services outsourced by the Department of Veteran Affairs (VA). Said RAC audit was terminated and RAC collections were limited to US$36 million of an estimated US$800 million in alleged overpayments. However, the VA has now broadened the scope of a new RAC to include all claims paid under the Veteran Affairs Community Cares programs, such as CHAMPVA, Spina Bifida, Patient-Centered Community Care, Veterans Choice Program, National Dialysis Contract, and Project Healthcare Effectiveness through Resource Optimization. Specific to DMEPOS, this new RAC will be auditing all claims paid through these programs from October 1, 2015, through September 30, 2023. Additionally, this presentation will address the impact of COVID-19 on government audits. One of the many results of COVID-19 waivers and flexibilities with be the impact they have on government audits, as they will likely affect areas of existing focus and create new areas for auditors to target. Lastly, this presentation will also highlight developments in case law for defending denials on a clinical basis and strategies for invalidating extrapolations.