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Course Details

Course Information
  • smart_display Format

    On-Demand

  • signal_cellular_alt Difficulty Level

  • work Practice Area

    Health

Date & Time
  • event Date

    Wednesday, November 2, 2022

  • schedule Time

    1:00 p.m. ET./10:00 a.m. PT

  • timer Program Length

    90 minutes

Credit Information

  • This 90-minute webinar is eligible in most states for 1.5 CLE credits.

$297.00
CLE
ALL

This CLE course will provide insight to counsel for Medicare and Medicaid providers on how to effectively evaluate and challenge overpayment determinations in provider audits using statistical sampling and extrapolation.

Faculty

Patricia L. Maykuth
President
Research Design Associates

Dr. Maykuth is a statistical expert with particular skill in experimental design, statistical sampling and methodology. She has been President of her firm for over 30 years. In that role she conducts and oversees a variety of statistical analyses of consumer behavior, market analyses and projections of market trends. She has been involved in more than 150 civil and criminal trials relating to statistics and consumer attitudes and behaviors. She has been directly responsible for statistical review of over 120 Medicare and Medicaid fair hearing officer and Medicare and Medicaid administrative law judge hearings which involved the application of statistical sampling and projection techniques in audits of a variety of categories of health care providers and suppliers. Her firm is frequently engaged to assist providors conduct Voluntary Repayment estimations and in establishing criteria for measurement in quality based payment systems.

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David R. Ross
Senior Shareholder
O’Connell and Aronowitz

Mr. Ross concentrates his practice on Medicaid, Medicare and private insurance audits & investigations, and health law including fraud and abuse, governmental investigations, criminal defense, administrative hearings, Federal and State False Claims whistleblower cases, Medicaid compliance plans, and Article 78 cases. He is the head of the firm's Government Investigations Unit and a member of the Healthcare Fraud and Abuse Unit. He held a number of high ranking positions within New York State government, including being appointed as General Counsel of the Office of the Medicaid Inspector General (OMIG) when the OMIG was created in response to widespread public concern about Medicaid fraud, waste and abuse. In addition to serving the OMIG as General Counsel, he was the Deputy Medicaid Inspector General for Audits and Investigations and oversaw all audits and investigations involving Medicaid providers.

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Description

Medicare and individual state Medicaid agencies routinely use samples of providers’ claims universes to extrapolate overpayment determinations. Each year, CMS informs Congress about the large dollar amounts it anticipates it will recoup from healthcare provider’s fraud and abuse activities. Many healthcare providers are impacted by these audits and must defend their documentation and other practices. To successfully challenge these audit determinations of overpayments that need to be repaid to federal health care programs, counsel for providers need to understand proper statistical sampling and extrapolation methods. They need to know how to identify and attack questionable methods and processes to minimize potential repayment obligations.

Government auditors’ statistical practices are presumed valid. it is the provider's burden to overcome that presumption and present sufficient credible evidence to refute the sampling and the extrapolation process. If the provider is successful, the extrapolated repayment amount will be removed from the case, leaving only the sample disallowances, which typically are relatively small and not worth challenging separately, to be repaid.

Listen as our authoritative panel illustrates how Medicare and Medicaid programs use statistical sampling and extrapolation to seek to recover very large dollar amounts of alleged Medicare and Medicaid overpayments. The panel will discuss how counsel for healthcare providers can obtain the information required to effectively challenge the sampling process and calculated demand amounts.

Outline

  1. Using samples to calculate overpayment dollar demands
    1. Proactive steps needed to mount the challenge: what must you do
    2. Due process
      1. Governmental experts and review processes (role and practice)
      2. Documentation necessary to replicate auditor work
      3. Cross examination
    3. Relevant cases, rulings, and regulations
      1. What is the MPIM
      2. Leveraging guidance from Medicare cases and the MPIM
    4. Impact of extrapolating from a sample – what matters to Administrative Law Judges
    5. Do you need a statistical expert
  2. Statistically valid probability sampling and extrapolation for accurate measurement of overpayments
    1. Demonstrating when the audit process is invalid
    2. Identifying fatal flaws in audit design and execution, including simple and stratified sampling
    3. The requirements of probability sampling
    4. Demonstrating when the overpayment demand is inaccurate
    5. CMS requirement of auditor reliability

Benefits

The panel will review these and other key issues:

  • Recognizing the statistical requirements auditors must meet to properly use the results of auditing a sample for extrapolation
  • Preparing your case utilizing the benefits of understanding probability statistics
  • Recognizing common mistakes auditors make that invalidate sampling methods
  • Making statistics accessible to attorneys challenging extrapolated audit findings