Three provider defenses reside within the SSA.
To defend against Recovery Audit Contractor (RAC), Medicare Administrative Contractor (MAC), or Targeted Probe-and-Educate (TPE) audits, we always fight claim by claim. We show that the clinical records support the service billed, despite what an auditor says. But there are other, more broad defenses that apply to providers found in the Social Security Act (SSA), even if the clinical arguments are weak.
Within the SSA, we have three strong provider defenses:
The “waiver of liability” defense provides that even if payment for claims is deemed not reasonable and necessary, payment may be rendered if the provider did not know and could not have been reasonably expected to know that payment would not be made. SSA, § 1879(a); 42 U.S.C. §1395pp; see also Medicare Claims Processing Manual (CMS-Pub. 100-04), Chapter 30, §20. =
Section 1870 of the SSA states that payment will be made to a provider if the provider was without “fault” with regard to the billing and accepting payment for disputed services. As a general rule, a provider would be considered without fault if it exercised reasonable care in billing for and accepting payment; i.e., the provider complied with all pertinent regulations, made full disclosure of all material facts, and on the basis of the information available, had a reasonable basis for assuming that the payment was correct. Here, there is no allegation of fraud; medically necessary services were rendered. The doctors performed a medically necessary service and should be paid for the service, despite nominal documentation nitpicking. The SSA does not require Medicare documents to be perfect; there is no requirement of documentation to be error-free.
It is well-settled law that the treating physician’s medical judgment as to the medical necessity of the services provided should prevail, absent substantial contradictory evidence. This means that the doctor who actually physically or virtually treated the consumer has a better vantage point than any desk review audit. Therefore, substantial deference should be given to the treating physician. This is especially important in proving medical necessity.
Lastly, even though this is not in the SSA, question the expertise of your auditors. If you are an MD and provide bariatric services, the auditor should be similarly qualified.
Programming Note:
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Following the release of the Centers for Medicare & Medicaid Services (CMS) proposed Physician Fee Schedule (PFS) for 2026, outpatient evaluation and management (E&M) coding
In an ideal world, every diagnosis code you submit to the Centers for Medicare & Medicaid Services (CMS) would be backed by bulletproof documentation –
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