Noridian, the Jurisdiction F Medicare Administrative Contractor (MAC), recently announced that they will be extending their pilot program: Provider Self-Audit with Validation and Extrapolation (PSAVE). Whenever a program is extended, that means that it has been successful for the payer, which likely means that they are saving money. It doesn’t state precisely HOW they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program.

What is PSAVE?

According to Noridian, “The PSAVE program allows the provider to perform a self-audit after agreeing to waive appeal rights on the universe of claims.” In exchange for waiving their appeal rights, the provider receives immunity from MAC and Recovery Auditor (RA) reviews.

Providers who voluntarily participate in PSAVE receive education on how to perform a self-audit. Noridian then validates the provider's self-audit findings on a subsample of claims. Here’s the catch, based on their findings, they “will extrapolate overpayments or correct underpayments.” The correcting underpayments is nice for the provider, but the extrapolation of underpayments process has been proven to be very costly to providers. CLICK HERE to read more about extrapolation.

According to the Noridian appeals waiver form (emphasis added), “It is important to note that the validation review may result in additional overpayments identified that may have been missed by the provider when the self-audit was conducted.”

Who May Participate?

Invitations to participate were sent to providers who were considered ‘outliers’ by Noridian. This means that their billing practices were already considered questionable. If you were invited, chances are that the self-audit may not prove to be a good option for your practice.

Participation Pros and Cons

Pros

Immunity from MAC and RA reviews could be a significant benefit if your claims are problematic. However, it is essential to note that immunity does NOT extend to Unified Program Integrity Contractor (UPIC) / Zone Program Integrity Contractor (ZPIC) or the Office of the Inspector General (OIG) so that immunity might not be as valuable as you think it is.

The educational aspects could prove to be beneficial to the practice by providing them with instructions to improve their claims and documentation process.

Cons

Waiving your appeals rights could be problematic, especially in situations like we are currently experiencing with the physical therapy denials by several Blue Cross organizations (e.g., Illinois, Texas).

Participation means that the practice will, in most cases, be unable to dispute the findings of the MAC. This is a pretty significant right to give up.

As mentioned earlier, immunity does not extend to all offices/organizations and their audits, so it’s value may be minimal.

Summary

Self-audits are a very good idea. However, we have some concerns about waiving your appeal rights. Rather than wait for a payer to tell you what you are doing wrong, find out yourself with your own self-audit and internally fix the problems immediately.

Note: Information about performing self-audits can be found in Chapter 3 of one of our specialty-specific Reimbursement Guides.

If you are invited to participate in PSAVE in the future, let that be a warning to you that your practice is already being considered for an audit. It should be a wake up call to ensure that your documentation and claims processes are in order.