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Earlier this year, the Health Care Financing Administration issued a program memorandum (PM) to help clarify the requirements carriers must follow when using statistical sampling in overpayment determinations. But experts say the PM significantly reduces the requirements that carriers must follow and gives them even more latitude in conducting their audits.
"What they have done is a huge step backwards because it gives the carriers no guidance in how they should be conducting these surveys," asserts Michael Intriligator, statistics professor at the University of California at Los Angeles. "They essentially threw out all the guidelines they had and gave carriers or intermediaries virtual carte blanche to do whatever they want."
Intriligator says the PM omits the previous basic sample size requirements as well as other requirements previously in place. It also reduces the amount of documentation required, he adds.
Health care attorney Lester Perling of Broad & Cassel in Fort Lauderdale, takes a similar view. "The vagueness of the guidelines are likely to lead to more litigation," he predicts.
He notes that the PM also states that if a sampling study has certain characteristics, then assertions that the sample and its resulting estimates are not "statistically valid" cannot legitimately be made. "In other words, the PM takes the position that a probability sample and its results are always valid,’" says Perling.
"The memorandum does state that the sample design must be properly executed,’" Perling adds. But exactly what that means will have to be addressed in future litigation, he contends.