You are the administrator for a small, busy, primary care physician practice (the “Practice”). The Practice treats
60% Medicare/Medicaid patients, 35% private insurance, and 5% self-pay. The Practice also operates its own
laboratory. The local CMS contractor has sent you a letter alleging that the Practice has been submitting claims
for improperly coded patient office visits and for lab work that is not indicated. The labs mostly relate to drug
screening of patients who are believed to be abusing or addicted to controlled substances (e.g., oxycodone).
CMS alleges that the practice is improperly maximizing reimbursement by: (i) billing for medically unnecessary
labwork, and (ii) claiming a higher level of service than what was actually provided to the patient.
The Practice has asked you to start drafting a repose letter. What might some of your arguments be to support
your Practice’s approach? In thinking and drafting, consider medical necessity standards, the state of
Medicare/Medicaid regulations, appropriate record documentation of office visits, patient improvement goals,
medical liability concerns, standard of care concerns, and patient preferences.

Sample Solution