Safeguard Services Audits and Appeals
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Safeguard Services, LLC is a Northeast Unified Program Integrity Contractor that the Centers for Medicare & Medicaid (CMS) uses for investigations of health care providers in Pennsylvania, Maryland, New Jersey, New York, Delaware, Connecticut, Vermont, Maine, Massachusetts, New Hampshire, Rhode Island, and the District of Columbia. The main function of Safeguard Services, LLC is to perform audits for the detection of fraud, waste and abuse within the Medicare Program.
The Role of Safeguard Services, LLC (SGS)
Safeguard Services detects potential problems through data analysis, medical review, and other investigation activities. Problems can include violations of the law including offering illegal kickbacks, routine waiver of co-payments, falsifying medical records, and billing for services not rendered. Problems can also include billing, coding and documentation issues such as failure to comply with national coverage determinations (NCDs) and local coverage determinations (LCDs) and failure to comply with national coding and billing guidelines.
SGS Investigations and Overpayment Determinations
Safeguard Services investigates suspected waste, fraud and abuse by analyzing medical records; analyzing claims and other data; interviewing patients; and interviewing of physicians, other healthcare providers and staff. Medical record review includes medical necessity determinations, evaluating services performed versus claims billed, and determinations whether if services as billed are payable. SGS works with law enforcement for civil and criminal prosecutions for Fraud or violations of other Federal laws including the False Claims Act and Anti-Kickback Statute.
What To Do If You Have Been Contacted By SGS Auditors or Investigators
1. Contact a health care lawyer immediately. Auditors and investigators who contact you have a purpose. Typically, they believe they have identified a problem and they want to pursue it. Do not get lulled into a false sense of security.
2. Determine what the problem might be. Getting out in front of the problem, so to speak, can be valuable. For starters, you want to take corrective action immediately. If the issue is billing for medically unnecessary services or reporting an improper code on the claim submission, you will want to make changes to your documentation or billing practices to prevent future errors. If the issue is an unlawful financial arrangement between providers, an attorney can help determine how to properly mitigate the problem.
3. How to determine what the problem is. The health care attorney can help identify legal issues such as improper financial relationships, unlawful intentional acts, improper delegation of services, errors on the claim form, or lack of proper physician supervision. Health care lawyers often retain a certified professional coder to assist with medical record review to verify compliance with documentation standards and whether services were billed properly.
4. Determine the exposure. Once the problem is identified, how serious is it? Is the problem a result of intentional acts or errors that should have been avoided? What is the financial risk if an overpayment is calculated? Does the problem amount to a violation of a Federal law? If so, what are the consequences (e.g. treble damages, civil penalties, exclusion from the Medicare program, imprisonment).
5. Preparing defense strategies. With the assistance of an experienced health care attorney, quick and aggressive action must be taken to appropriately respond to an investigation or audit. An attorney can help identify the proper scope of the investigation, determine flaws within a methodology, determine what information should be made available to the investigators, and dispute the allegations.
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