Is there such a thing as a routine Medicare audit?
Although you may speak of a "routine" Medicare audit, there is really no such creature. This is like saying you have a "routine IRS audit." The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.
Where does the Medicare audit take place?
You will often find that the Medicare audit and the site visit will occur at the branch office that appears on the claim form that you submit to the CMS. If a visit is to be scheduled at one of the offices in your practice, you want to ensure that the office is fully staffed and operational when the auditors get there.
What do auditors ask for in a Medicare audit letter?
In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.
How often are CERT audits conducted?
Certified Error Rate Testing (CERT) audits According to the CMS website, CERT audits are conducted annually using “a statistically valid random sample of claims.” Auditors review the selected claims to determine whether they “were paid properly under Medicare coverage, coding, and billing rules.”
What triggers Medicare audit?
What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.
What happens if you fail a Medicare audit?
If you fail to comply with the request, you will not receive reimbursement for the submitted claims. Even if you comply but the documentation doesn't support what you billed for, you won't get reimbursement.
Who gets audited by Medicare?
For example, the Medicare program is required to make random audits of 10% of all Medicare providers on an ongoing basis. An audit or investigation can result from complaints by patients about the quality or appropriateness of the care they received, or how they were billed for their care.
How far back does a Medicare audit go?
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.
What will the Medicare auditor check during the audit?
Medicaid and Medicare auditors are briefed to scrutinize healthcare professionals on procedures for prescribing pain medications and narcotics to beneficiaries. So, brush up on California's opioid regulations and insurance coverage rules for pain management on Medicare, as well as others.
How long does a Medicare audit take?
After the provider is “targeted” using data analytics, the MAC performs up to three rounds of "probe and Educate." Each round takes about 90 days—30 days for MAC to review the claims, a few days to schedule an educational call, 45 days for providers to show improvement—and is centered around a one-on-one educational ...
How far back can Medicare go to recoup payments?
3 calendar yearsFor Medicare overpayments, the federal government and its carriers and intermediaries have 3 calendar years from the date of issuance of payment to recoup overpayment. This statute of limitations begins to run from the date the reimbursement payment was made, not the date the service was actually performed.
What is a Medicare OIG audit?
Under this authority, OIG conducts audits of internal CMS activities, as well as activities performed by CMS grantees and contractors. These audits are intended to provide independent assessments of CMS programs and operations and to help promote economy and efficiency.
What are CMS audits?
These program audits measure a Sponsoring organization's compliance with the terms of its contract with CMS, in particular, the requirements associated with access to medical services, drugs, and other enrollee protections required by Medicare.
How do I respond to a Medicare audit?
How to Respond to a Medicare AuditTake all correspondence from Medicare, or the Medicare contractor, seriously.Read the audit letter carefully and provide all the information requested in the letter.Include a copy of the complete record and not just those from the dates of service requested in the audit letter.More items...
What is the lookback period for overpayments?
within six yearsThe rule also states that an overpayment must be reported and returned if it is identified within six years of the date it was received. This time period is generally referred to as the “lookback” period.
Can you alter a medical record after an audit?
Never alter the medical records after a notice of an audit. However, if there are consults, orders, test reports, prescriptions, etc., that have not been filed into the chart, yet, have these filed into it, as you normally would, so that the record is complete.
Is a summary a substitute for medical records?
The summary is not a substitute for the medical records, but will assist an auditor that may not be experienced in a particular specialty or practice area. Make sure that any such summaries are clearly marked as summaries with the current date they are actually prepared. Label it accurately.
Should Medicare contractor be taken seriously?
All correspondence from Medicare, or the Medicare contractor, should be taken seriously. Avoid the temptation to consider the request from Medicare, or the Medicare contractor, just another medical records request. Avoid the temptation to delegate this as a routine matter to an administrative employee.
Is Medicare a routine audit?
Although you may speak of a "routine" Medicare audit, there is really no such creature. This is like saying you have a "routine IRS audit." The fact is that there is some item you have claimed as a Medicare provider or the amount of claims Medicare has paid in a certain category that has caused you or your practice to be audited.
Do auditors ask for medical records?
In addition to medical records, auditors often ask for invoices and purchase orders for the drugs and medical supplies dispensed to patients for which Medicare reimbursed you. Include a copy of the complete record and not just those from the dates of service requested in the audit letter.
What do Medicare auditors take?
Auditors will most likely take pictures of several things – including photographs, diplomas, letters , awards, and licenses. Ensure that none of these are expired – or worse, false. For Medicare pharmacy audits, the auditors might also inspect cabinets and drawers to snap what’s inside them.
What to do if you are subject to Medicare audit?
If you are subject to a Medicare audit, make sure to do your due diligence in research before selecting an attorney. Your business is at risk, so it is crucial that your representation has experience and a history of success in this field.
What is CERT audit?
CERT audits are primarily conducted using a “statistically valid random sample of claims.” The auditor will essentially review a specific number of claims to determine whether they are appropriately paid under all applying rules.
Do auditors want a private room?
The auditors will most likely want a private, separate room that they can use and have their meetings in. Ensure that the room is clean and that fixtures are in top shape. Remember that the auditors might want to conduct interviews with all employees.
Should you brush up on intelligence questions before an auditor visit?
You should brush up on answers to questions that you may be asked before the auditors visit. However, remember that this isn’t an intelligence test. Your employees will need to answer questions truthfully.
