Posted and filed under Fraud, FWA, Healthcare.

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Why do a statistically valid random sample (SVRS)?

In my role at Advize Health, I frequently field this question from both providers seeking proactive audits for their compliance programs and from law firms we work with on a variety of topics.

An SVRS is a way to obtain, with a high level of confidence, what an overpayment is when a large amount of patient records needs to be reviewed. In situations where the volume of records that need to be reviewed spans across several years, SVRS makes it easy to sift through an astronomical amount of documentation. There are numerous software platforms that can run the SVRS, but RAT-STATS is the OIG standard.

When speaking to various groups that are engaging Advize for a review (Advize does not do coding and billing on the front end, we provide consulting and advisory services on the back-end for compliance, fraud, waste and abuse), I am often asked if an SVRS is necessary.  Although I’m not a lawyer, I unfortunately must give the lawyer response: “it depends”. What is the purpose of the review? – is always the question.  Although an SVRS May have some additional costs involved (due to the time involved in running the sample, and the review of what is typically a 100-record review), it is a better option than probe sample. Probe samples have no statistical significance, and an SVRS would likely have to be done anyway.

Any provider seeking to make a self-disclosure to the OIG (and I present and discuss this protocol extensively because I do believe it is a great program) will need to do an SVRS.  Any provider seeking to create a stronger compliance program should be considering a yearly (or more) SVRS to identify areas where billings need to be resubmitted for adjustment, or where codes were actually under billed and should be resubmitted.  Correct coding is an important part of a compliance plan and identifying under coding is just as important as upcoding.

CMS encourages Medicare contractors, such as the UPICs and the MACs to use RAT-STATS for sampling, so it is important think about that when selecting a sample proactively or reactively.  Advize has used RAT-STATS for years.  It has been court tested, is considered the gold standard for SVRS samples, and saves a lot of time in the end by not having to demonstrate its effectiveness.

Always consider an SVRS over a probe sample for any reviews.  A probe will just have to be replaced by an SVRS anyway.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.