Claim to Fame
DME Audits, UPICs, Extrapolation, and AI: Legal Insights with Stephen Bittinger
On the Claim to Fame DME podcast, healthcare attorney Stephen Bittinger of Polsinelli explains how he defends providers against payer audits and sues payers for unpaid or denied claims. He says DME suppliers are frequent audit targets due to complex, changing rules, often identified through payer data mining or watch lists. Common provider mistakes include poor document production; he advises making records organized, chronological, and easy for auditors. He recommends legal counsel especially for UPIC or Medicaid MFCU audits and whenever statistical sampling and extrapolation is involved, where small sampled overpayments can be projected into large demands over long look-back periods (commercial typically two years; Medicare four). He describes rising AI-driven denials and litigation, warns providers that AI doesn’t change claim-submission responsibility, and flags CMS’s WISER AI preauthorization pilot in six states. His core advice: know LCD/NCD requirements, maintain QC, and conduct quarterly internal self-audits. (Stephen notes he does not represent NikoHealth or endorse its services).
