In the current political environment, the future of the Affordable Care Act and other health care initiatives is likely to look very different than they do now. However, two initiatives are expected to continue, the movement toward value-based payments, and audits to prevent and recover improper payments.
In this issue we will look at some of the current health care fraud and abuse programs and discuss what you can do to prepare your practice.
HEALTH CARE FRAUD AND ABUSE CONTROL PROGRAMS 1, 2, 3
The Office of Inspector General (OIG) has broad responsibility for audits and investigations and many of their initiatives impact health care providers. The various health care fraud and abuse programs that the OIG is involved with safeguard health care dollars and protect health care consumers.
In October 2016, the Health and Human Services (HHS) OIG celebrated its 40th year in existence. The Inspector General Act (IG Act) was signed into law by President Gerald Ford on October 15, 1976. This was followed by the Inspector General Act of 1978 which mandated reporting requirements including annual and semi-annual reports to Congress, the review of legislation and regulations, establishment and coordination of working relationships with Federal, State, local and private entities, and the authority to audit and investigate all Departmental programs.
In addition to their legal authority under the IG Acts, the HHS OIG has the legal authority to conduct investigations and audits under the Civil Monetary Penalties Law, and the Physician Self-Referral (Stark) Law, to audit enforcement of the Health Insurance Portability and Accountability Act's (HIPAA's) privacy standards, and to exclude individuals and entities convicted of certain offences from participation in all Federal health care programs.
The stated mission of the HHS OIG is to protect the integrity of Department of Health & Human Services (HHS) programs as well as the health and welfare of program beneficiaries. They work to accomplish this through a variety of programs and initiatives.
Most health care professionals recognize the OIG's role in safeguarding the Medicare and Medicaid programs. However, the OIG is also charged with combatting fraud committed against private health plans.
The Health Insurance Portability and Accountability Act of 1996 (HIPAA), established a national Health Care Fraud and Abuse Control Program (HCFAC), under the joint direction of the Attorney General and the HHS Secretary. The HCFAC program coordinates Federal, State and local law enforcement activities with respect to health care fraud and abuse in both public and private health plans.
A recent report, The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016, published in January 2017, details expenditures and revenues under the HCFAC program. According to the report, HCFAC returned over $3.3 billion to the federal government or private individuals as a result of its health care enforcement efforts in fiscal year (FY) 2016.
The report also includes the calculation of the return on investment (ROI) for the HCFAC program. Based on a three-year rolling average, the ROI for the program for years 2014-2016 is $5.00 returned for every $1.00 expended, for a 400% ROI.
Return on Investment Calculation:
ROI = ( (Earnings) - Initial Invested Amount) / Initial Invested Amount) ) x 100
In addition to the program results and accomplishments, the report also includes summary information on successful criminal and civil investigations initiated or concluded in FY 2016 including claims of violations of the False Claims Act (FCA). This information is helpful in understanding the current health care fraud investigative and enforcement environment.
The Health Care Fraud Prevention and Enforcement Action Team (HEAT) 4, 5
The Health Care Fraud Prevention and Enforcement Action Team (HEAT), is a joint initiative between HHS, OIG, and the Department of Justice (DOJ). HEAT was created in 2009 by HHS and the DOJ to strengthen Medicare and Medicaid program integrity and to invest new resources and technologies to prevent and combat health care fraud, waste and abuse.
The Medicare Fraud Strike Force is a component of HEAT consisting of an interagency task force team comprised of OIG and DOJ analysts, investigators, and prosecutors. The Medicare Fraud Strike Force targets emerging or migrating fraud schemes, including fraud by criminals masquerading as health care providers or suppliers.
In a Fact Sheet dated January 18, 2017, CMS states that in June 2016, the Medicare Fraud Strike Force conducted a nationwide health care fraud takedown resulting in criminal and civil charges against 301 individuals, including 61 doctors, nurses and other licensed medical professionals, for participation in approximately $900 million in false billings.
HEAT has expanded the Medicare Fraud Strike Force to include nine locations:
- Baton Rouge, Louisiana
- Brooklyn, New York
- Chicago, Illinois
- Dallas, Texas
- Detroit, Michigan
- Houston, Texas
- Los Angeles, California
- Miami-Dade, Florida
- Tampa Bay, Florida
DATA ANALYSIS AND MINING TO DETECT FRAUD 6
In September 2012, the HHS Secretary and US Attorney General established the Healthcare Fraud Prevention Partnership (HFPP) with the goal of fostering a proactive approach to detect and prevent healthcare fraud through the voluntary sharing of data and information.
The HFPP is a voluntary public-private partnership between the federal government, state agencies, law enforcement, private health insurance plans, and healthcare anti-fraud associations. The HFPP focuses on data sharing and analytics, and training, outreach, education and information sharing.
The goals of the HFPP include the exchange of data and information between public and private sectors, leveraging analytic tools against data sets provided by HFPP partners and providing a forum to share successful anti-fraud practices and effective methodologies for detecting and preventing healthcare fraud.
In addition to federal and state partners, the HFPP also counts many private payers as partner organizations including the following:
- Blue Cross and Blue Shield of Alabama
- Blue Cross and Blue Shield of Kansas
- Blue Cross and Blue Shield of Louisiana
- Blue Cross and Blue Shield of Nebraska
- Blue Shield of California
- CareFirst Blue Cross Blue Shield
- Central Health Plan of California
- Emblem Health
- Fidelis Care New York
- Florida Blue
- Geisinger Health Plan (GHP)
- Health Alliance Plan
- Health Care Service Corporation
- Healthfirst, Inc.
- Horizon Blue Cross and Blue Shield
of New Jersey
- Independence Blue Cross
- Kaiser Permanente
- Magellan Health
- Medical Mutual of Ohio
- Moda Health
- Molina Healthcare
- Premera Blue Cross
- SCAN Health Plan
- Sentry Insurance
- The Hartford
- Tufts Health Plan
- United HealthCare
OIG EXCLUSION LIST 7, 8, 9, 10
The OIG publishes and maintains a List of Excluded Individuals/Entities (LEIE) to provide information to the health care industry, patients and the public on individuals and entities that are excluded from participation in Medicare, Medicaid and all other Federal health care programs.
The OIG's Exclusions Program was implemented to protect Medicare and Medicaid beneficiaries and to prevent certain individuals and businesses from participating in federally funded healthcare programs. Providers and other individuals may be excluded from the Medicare and Medicaid programs for a variety of reasons including convictions for program-related fraud and patient abuse or neglect, licensing board actions and default on Health Education Assistance Loans.
Congress first mandated the exclusion of physicians and other practitioners convicted of program-related crimes from participation in Medicare and Medicaid in 1977, in the Medicare-Medicaid Anti-Fraud and Abuse Amendments, Public Law 95-142, this has since been codified in section 1128 of the Act.
The OIG lists the following mandatory and permissive exclusions:
Mandatory exclusions: OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances.
Permissive exclusions: OIG has discretion to exclude individuals and entities on a number of grounds, including misdemeanor convictions related to health care fraud other than Medicare or a State health program, fraud in a program (other than a health care program) funded by any Federal, State or local government agency; misdemeanor convictions relating to the unlawful manufacture, distribution, prescription, or dispensing of controlled substances; suspension, revocation, or surrender of a license to provide health care for reasons bearing on professional competence, professional performance, or financial integrity; provision of unnecessary or substandard services; submission of false or fraudulent claims to a Federal health care program; engaging in unlawful kickback arrangements; and defaulting on health education loan or scholarship obligations; and controlling a sanctioned entity as an owner, officer, or managing employee.
The Effect of Exclusion
The primary effect of an exclusion is that no payment will be made by any Federal health care program for any items or services furnished, ordered, or prescribed by an excluded individual or entity. This includes Medicare, Medicaid, and all other Federal plans and programs that provide health benefits funded directly or indirectly by the United States (other than the Federal Employees Health Benefits Plan).
Furthermore, the OIG clearly states that this payment prohibition applies to the excluded person, anyone who employs or contracts with the excluded person, any hospital or other provider for which the excluded person provides services, and anyone else. The exclusion applies regardless of who submits the claims and applies to all administrative and management services furnished by the excluded person.
The exclusion prohibition is not limited to clinical staff or items or services involving direct patient care, but extends to services including administrative and management services that are not separately billable. The 2015 CMS Resource Guide, Laws Against Health Care Fraud Resource Guide states the following, "If, for example, a biller is excluded from a government health care program, payments on claims submitted by the practice through the biller may be considered overpayments subject to recoupment."
Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). Under the Civil Monetary Penalties Law, Social Security Act Section 1128A, HHS-OIG may impose civil monetary penalties of up to $10,000 per item or service claimed while excluded. HHS-OIG may also impose an assessment of up to three times the amount claimed.
Take These Steps to Avoid Hiring an Excluded Individual or Entity
To avoid CMP liability, health care entities should check the LEIE prior to a new hire and routinely thereafter to ensure that current employees are not on the excluded list. The List of Excluded Individuals/Entities (LEIE) database is available at http://exclusions.oig.hhs.gov/ on the HHS-OIG website.
You can download the LEIE and sort the database by field including: name, business name, specialty, address, city, or state. Alternatively, the Exclusions Program Online Searchable Database allows users to enter the name of an individual or entity to determine if they are currently excluded. If a name match is made, the database will verify the match using a Social Security Number or Employer Identification Number.
The OIG updates the LEIE monthly. And while there is no legal requirement that providers check the LEIE, the OIG strongly recommends that providers screen employees and contractors each month to minimize potential overpayment and CMP liability.
A quick search of the January 2017 LEIE downloadable database reveals that 27 oncologists are currently on the OIG Exclusion list.
The OIG suggests that providers maintain documentation of all searches performed in order to verify the results of potential name matches. You can document exclusions checks performed by using the "Print Search Results" button that appears on the screen with the search results. The screen shot will include the name searched, and whether or not the individual or entity is currently excluded, the type of exclusion (when applicable), the date and time that the search was conducted, and the date and time that the source data was updated.
Have you Hired or Contracted with An Excluded Individual or Entity?
If you discover that you have employed or contracted with an excluded individual or entity, it is suggested that you contact your health care attorney about self-disclosing this information to the OIG using the OIG's Self-Disclosure Protocol ("SDP"). The OIG's SDP contains specific guidance on making disclosures involving exclusions, and includes information on how to calculate potential overpayments.
If you are self-disclosing that you have employed or contracted with an excluded individual or entity you must provide (in addition to the general information required) the following information:
- The identity of the excluded individual and any provider identification number.
- The job duties performed by that individual.
- The dates of the individual's employment or contractual relationship.
- A description of any background checks that the disclosing party completed before and/or during the individual's employment or contract.
- A description of the disclosing party's screening process (including any policy or procedure that was in place) and any flaw or breakdown in that process that led to the hiring or contracting with the excluded individual.
- A description of how the conduct was discovered.
- A description of any corrective action (including a copy of any revised policy or procedure) implemented to prevent future hiring of excluded individuals.
In addition to monitoring the OIG LEIE database, providers should also check their State Medicaid Exclusion list.
OIG WORK PLAN 2017 11
The OlG publishes a yearly Work Plan identifying various projects to be addressed during the fiscal year by the Office of Audit Services, Office of Evaluation and Inspections, Office of Investigations, and Office of Counsel to the Inspector General. The OIG Work Plan includes projects planned in the Centers for Medicare & Medicaid Services (CMS) as well as other departments.
A review of the Work Plan will tell you what the OIG is focusing on and will help you to identify vulnerabilities and risks in your practice. The OIG description of the target areas provides information on the potential problem as seen by the OIG, and the scope and timeline of their investigation.
The 2017 OIG Work Plan includes the following Medicare and Medicaid reviews and activities:
Medicare Payments for Transitional Care ManagementTransitional Care Management (TCM) includes services provided to a patient whose medical and/ or psychosocial problems require moderate or high-complexity medical decision-making during transitions in care from an inpatient hospital setting (including acute hospital, rehabilitation hospital, long-term acute care hospital), partial hospital, observation status in a hospital, or skilled nursing facility/nursing facility, to the patient's community setting (home, domicile, rest home, or assisted living). The OIG will determine whether payments for TCM services were in accordance with Medicare requirements.
Medicare Payments for Chronic Care Management
Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions (Alzheimer's disease, arthritis, cancer, diabetes, etc.) that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These significant chronic conditions are expected to last at least 12 months or until the death of the patient. CCM cannot be billed during the same service period as transitional care management, home health care supervision/ hospice care, or certain end-stage renal disease services. Beginning January 1, 2015, Medicare paid separately for CCM under the Medicare Physician Fee Schedule and under the American Medical Association Current Procedural Terminology. The OIG will determine whether payments for CCM services were in accordance with Medicare requirements.
Drug Waste of Single-Use Vials
The FDA approves vial sizes for single use submitted by manufacturers but does not control the vial sizes submitted for approval. Savings might be realized if single vial sizes currently available in other countries were available in the United States and if manufacturers were to market these smaller vials at lower prices. The Medicare Claims Processing Manual, Pub. 100-04, Ch. 17, § 40 provides policy on the use of the "JW" modifier for discarded Part B drugs and biologicals to track the amount of reimbursed waste in single-use vials effective January 1, 2017. The OIG will determine the amount of waste for the 20 single-use-vial drugs with the highest amount paid for waste as identified by the JW modifier and provide specific examples of where a different size vial could significantly reduce waste.
Data Brief on Financial Interests Reported Under the Open Payments Program
The Physician Payments Sunshine Act (from the ACA § 6002) requires that manufacturers disclose to CMS payments made to physicians and teaching hospitals. Manufacturers and group purchasing organizations must also report ownership and investment interests held by physicians. We will analyze 2015 data extracted from the Open Payments website to determine the number and nature of financial interests. We will also determine how much Medicare paid for drugs and DMEPOS ordered by physicians who had financial relationships with manufacturers and group purchasing organizations. The OIG will determine the volume and total dollar amount associated with drugs and DMEPOS ordered by these physicians in Medicare Parts B and D for 2015.
Prolonged Services - Reasonableness of Services
Prolonged services are for additional care provided to a beneficiary after an evaluation and management (E/M) service has been performed. Physicians submit claims for prolonged services when they spend additional time beyond the time spent with a beneficiary for a usual companion E/M service. The necessity of prolonged services are considered to be rare and unusual. The Medicare Claims Processing Manual includes requirements that must be met in order to bill for a prolonged E/M service code (Medicare Claims Processing Manual, Pub. 100-04, Ch. 12, § 184.108.40.206). The OIG will determine whether Medicare payments to physicians for prolonged E/M services were reasonable and made in accordance with Medicare requirements.
MEDICARE RECOVERY AUDIT PROGRAM 12, 13, 14
The Medicare Recovery Audit Program began as a demonstration program in six states in 2005. Due to the initial success of the Recovery Audit program in identifying and recouping overpayments, the Tax Relief and Health Care Act of 2006 mandated that a permanent and national RAC program be in place by January 1, 2010.
The Recovery Audit Contractors (RACs) are paid on a contingency fee basis for both recovering overpayments from providers and identifying underpayments to providers. The amount of the contingency fee is a percentage of the overpayment or underpayment and is negotiated by the RACs during the time of the award contract.
In their Fiscal Year (FY) 2014 report to Congress, CMS reported that RAC audits resulted in $2.39 billion in overpayments collected and $173.1 million in underpayment repaid to providers. After all program costs were taken into account the Recovery Audit program returned over $1.6 billion to the Medicare Trust Fund.
Still, criticism of the program grew as providers and hospitals reported concerns including the administrative burden of responding to the RAC's additional documentation requests (ADRs), a lack of timely communication from the RACs regarding claim status, an overly long look-back period of 3-years and the fact that RACs were paid their contingency fee immediately upon denial and recoupment of the claim.
In a February 10, 2014 letter to HHS Secretary Kathleen Sebelius, 111 members of Congress called for the reform of the RAC process stating that the RACs are incentivized to deny claims, even when the claims are correct, thus leaving hospitals and providers with immense administrative burdens related to appealing the denied claims in order to be reimbursed for the Medicare services provided.
The letter cites a November 2012 OIG report, which states that 72 percent of hospital Medicare Part A appeals that have reached the third level of the Medicare appeals process are overturned in favor of the hospitals. Furthermore, the unprecedented increase in the decisions being appealed to the Office of Medicare Hearings and Appeals (OMHA) resulted in a backlog of appeals at the Administrative Law Judge (ALJ) of at least two years.
The letter ends with the request that the Centers for Medicare & Medicaid Services (CMS) immediately reform the RAC process and to adopt an alternative payment method with the RACs so they are not improperly incentivized to deny claims for profit.
In response to the criticism from health care organizations and Congressional members, CMS temporarily suspended all RAC audit activity through 2014.
Subsequently, when the program began a restart in 2015, it was on a restricted basis and under new program changes that CMS says addresses the concerns raised and that will provide enhanced oversight, reduced provider burden, and more program transparency.
New Medicare RACs Announced
On October 31, 2016 the Centers for Medicare & Medicaid Services (CMS) announced the new Recovery Audit Contractors (RACs) for Medicare Fee for Service (FFS):
- Region 1 Performant Recovery Services
- Region 2 Cotiviti LLC (formerly known as Connolly Consulting)
- Region 3 Cotiviti LLC (formerly known as Connolly Consulting)
- Region 4 HMS Federal Solutions
- Region 5 Performant Recovery Services
With the announcement of the new RAC contracts, CMS also specified the program enhancements, some of which became effective in 2015. Of note, the new look-back period is limited to six months from the date of service for patient status reviews when the hospital submits the claim within three months of the date of service (down from the previous look-back period of three years). However the look-back period remains up to three years for other provider services.
The RACs will now have 30 days to complete complex reviews and notify providers of their findings (previously RACs had 60 days to complete these reviews).
Modifications to the new RAC contracts included a change in the timeline for payment of the RAC contingency fees. In the past, the RACs were paid immediately upon denial and recoupment of the claim, under the new contracts the RACs will not receive a contingency fee until after the second level of appeal is exhausted.
Criticism of the RAC program included the fact that the RACs were not penalized for high appeal overturn rates. This led to charges that the RACs were incentivized to deny claims, even if the claims were correct. Under the new oversight enhancement, RACs will be required to maintain an overturn rate of less than 10% at the first level of appeal, excluding claims that were denied due to no or insufficient documentation or claims that were corrected during the appeal process. Failure to maintain the overturn rate of less than 10% will result in CMS placing the RAC on a corrective action plan. In addition, they will be required to maintain an accuracy rate of at least 95% and failure to do so will result in a progressive reduction in ADR limits.
Figure 1: Medicare FFS RAC MAP November 2016 cms.gov
Figure 1 illustrates the new RAC regions and RACs. The RACs in Regions 1-4 will perform post-payment review to identify and correct Medicare claims that contain improper payments (overpayments or underpayments) that were made under Part A and Part B, for all provider types other than Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) and Home Health/Hospice.
The Region 5 RAC will be dedicated to the post-payment review of DMEPOS and Home Health/Hospice claims nationally.
MEDICARE FEE FOR SERVICE RAC CONTACT INFORMATION
E-mail / Phone Number
Region 1: Performant Recovery, Inc.
States: CT, MI, IN, ME, MA, NH, NY, OH, KY, RI and VT
Region 2: Cotiviti, LLC
States: IL, MN, WI, NE, IA, KS, MO, CO, NM, TX, OK, AR, LA, and MS
Region 3: Cotiviti, Inc.
States: AL, FL, GA, NC, SC, TN, VA, WV, Puerto Rico and U.S. Virgin Islands
Region 4: HMS Federal Solutions
States: AK, AZ, CA, DC, DE, HI, ID, MD, MT, ND, NJ, NV, PA, OR, SD, UT, WA, WY, Guam, American Samoa and Northern Marianas
Region 5: Performant Recovery, Inc.
Nationwide for DMEPOS/HHA/Hospice
It is unlikely that the pace and number of audits will decrease anytime soon. However, there are steps you can take to reduce the chances of a targeted audit and to improve your chances of prevailing in the event that you are audited.
First, make sure that you have adequate staffing to review current audit issues, perform internal risk assessments, identify areas of opportunity for compliance improvement, and to respond quickly and appropriately to any requests for additional information and audits.
- Assign a staff member to act as Audit Coordinator, this person must be detail oriented and have sufficient time to devote to audit activities.
- Organize your audit team and assign responsibilities.
- Identify your practice risk areas by evaluating patterns of current denials, issues identified internally through audit and compliance activities, and issues posted to the RAC web sites.
- Review the following:
- The Medicare Quarterly Compliance Newsletter, this newsletter addresses common billing errors and other claim review findings. It is updated quarterly and available on the Medicare Learning Network. Archived newsletters are available here: www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/MedQtrlyCompNL_Archive.pdf
- The Office of Inspector General (OIG) Work Plan
- Comprehensive Error Rate Testing (CERT) reports identify and address billing errors concerning coverage and coding. CERT reports are available on your Medicare Administrative Contractor's (MACs) website.
- Review medical record documentation for:
- Proper diagnoses
- Medical necessity
- Correct coding and use of modifiers
- Develop tracking process:
- Track record requests, type of service audited, records submitted, date of response, whether there was an overpayment, date of recoupment, requests for redetermination and/or appeals, outcome of appeals.
1 Protecting Public Health and Human Services Programs: A 30-Year Retrospective. oig.hhs.gov/publications/docs/retrospective/AnniversaryPub.pdf. Accessed February 01, 2017.
2 Office of Inspector General U.S. Department of Health & Human Services. https://oig.hhs.gov. Accessed February 01, 2017.
3 The Department of Health and Human Services And The Department of Justice Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2016. oig.hhs.gov/publications/docs/hcfac/FY2016-hcfac.pdf. Accessed February 01, 2017.
4 U.S. Department of Health & Human Services. Heat Task Force. www.stopmedicarefraud.gov/aboutfraud/heattaskforce/. Accessed February 01, 2017.
5 CMS.gov. Fact Sheet: The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by Combating Health Care Fraud. www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-01-18-2.html. Accessed February 01, 2017.
6 CMS.gov. Healthcare Fraud Prevention Partnership. hfpp.cms.gov/about/background.html. Accessed February 2, 2017.
7 Office of Inspector General U.S. Department of Services. Exclusions Program. oig.hhs.gov/exclusions/index.asp. Accessed February 02, 2017.
8 Office of Inspector General U.S. Department of Services. Specialty Advisory Bulletin. Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal health Care Programs. oig.hhs.gov/exclusions/advisories.asp. Accessed February 02, 2017.
9 CMS.gov. Laws Against Health Care Fraud Resource Guide. www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-laws-resourceguide.pdf. Accessed February 02, 2017.
10 Updated OIG's Provider Self-Disclosure Protocol
oig.hhs.gov/compliance/self-disclosure-info/files/Provider-Self-Disclosure-Protocol.pdf. Accessed February 02, 2017.
11 U.S. Department of Health & Human Services Office of Inspector General. OIG Work Plan 2017. oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf. Accessed February 02, 2017.
12 CMS.gov. Medicare Fee for Service Recovery Audit Program. www.cms.gov/research-statistics-data-and-systems/monitoring-programs/medicare-ffs-compliance-programs/recovery-audit-program/recent_updates.html. Accessed February 02, 2017.
13 CMS.gov.Recovery Audit Program Enhancements.
www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Recovery-Audit-Program-Enhancements11-6-15-Update-.pdf. Accessed February 02, 2017.
14 Letter to Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services. American Hospital Association. www.aha.org/content/14/140210-let-congress-hhs.pdf. Accessed February 03, 2017.