How to prepare for a medicare audit
- Comply with deadlines. Most CMS notifications arrive by mail, so make sure your front office knows what to do with these letters when they’re received. ...
- Educate your office staff. ...
- Gather all requested information and documents. ...
- If you’ve been audited by CMS previously, review those audits. ...
- Who will meet with the auditor? ...
Full Answer
How can I protect my practice from Medicare audits?
but it’s possible to manage the audit challenge. To help prepare you to deal with this likely occur-rence, we offer guidance for compliant documenta-tion and timely response to auditors. These practical steps can ease the audit discomfort and enable you to focus on caring for patients. AudIts HAppen The Centers for Medicare and Medicaid Services
Are your DME suppliers prepared for a Medicare audit?
Preparing for a Medicare Audit Visit. Check the address on the letter and ensure that it is the address of your practice. This tip is critical if you’ve yet to update your physical address ... Make contact with the auditors. Keep copies of all transmitted documents to the auditors. Get in …
How do I prepare for a UPIC audit?
Nov 24, 2021 · How to Prepare for a Medicare Audit Comply with deadlines. Most CMS notifications arrive by mail, so make sure your front office knows what to do with these letters when they’re received. CMS only allows a window of 45 days to respond, so time is of the essence and unpaid claims may be the result of missing the deadline. Educate your office staff.
What happens if you do not comply with a Medicare audit?
Sep 18, 2018 · Let’s look at some ways that you can prepare for a CMS audit by using their published guidelines as a reference point. What the New Initiatives Mean for CMS Audits Announced in June, here are the initiatives that CMS has begun to focus on: Increased emphasis on program integrity in audits. New audits for state beneficiary eligibility.
How do you pass a Medicare audit?
The key to passing these audits is to keep your cool, have your policy and procedures up to date, and make sure your documentation will pass their review. Every MAC (Medicare Administrative Contractor) will have an LCD (Local Coverage Determinations) manual. Make sure you are following the guidelines set forth in it.Feb 21, 2020
What does Medicare look for in an audit?
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.”Jul 16, 2014
How do you prepare for an audit in healthcare?
Here are our top seven tips to prepare for a healthcare compliance audit.Examine your last risk assessment or prior audit results. ... Ensure you have an audit trail. ... Pull together the pieces of the audit's focus. ... Break down the audit scope into manageable pieces.More items...•Aug 24, 2018
What happens when you get audited by Medicare?
Medicare audits are one of several things that can trigger a larger civil or criminal investigation by federal law enforcement. Usually, auditors con- clude that Medicare has made significant “over- payments”and demand that the audited physician return the money.
How far back can Medicare audit go?
three yearsMedicare 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.Nov 1, 2015
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.Jan 6, 2015
What are the five process steps to an audit?
There are five phases of our audit process: Selection, Planning, Execution, Reporting, and Follow-Up.
What are the 7 pillars of clinical governance?
The 7 Pillars of Clinical Governance Clinical Effectiveness and Research. Audit. Risk Management. Education and Training. Patient and Public Involvement. Information and IT. Staff Management.Apr 25, 2018
What are the steps of clinical audit?
1) Selecting a topic. 2) Agreeing standards of best practice (audit criteria). 3) Collecting data. 4) Analysing data against standards.
How long do Medicare audits 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 ...Jan 17, 2018
What triggers a Medicaid audit?
Medicaid is federally prohibited from paying providers who are not correctly enrolled with them. Repeated claim submissions that include the use of non-enrolled providers will most certainly raise the Medicaid audit red flag. There can be many reasons that a provider might not be enrolled with Medicaid.Sep 1, 2021
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 do auditors request?
Auditors typically will request a list of every medication prescribed, dispensed, used, or billed for in your practice. They will follow up by asking for copies of all invoices for all drugs ordered, dispensed, or billed by your practice.
What to do if you don't know the answer to a question?
Before the site visit, instruct your staff members that if they don’t know the answer to a question, they simply should say so to the auditor when they are interviewed. Remind staff members that an audit is not an intelligence test and that staff members cannot fail the audit because they do not knowww an answer.
What does it mean when a letter comes across your office fax machine?
A letter comes across your office fax machine indicating that your practice has been scheduled for an audit and site visit from the Centers for Medicare and Medicaid Services, a Medicare administrative contractor, or a zone program integrity contractor the next morning at 8 a.m. Sound far-fetched? This exact scenario is likely if your practice is scheduled for such a visit from the federal government or a government contractor. The timing is intended to give you little chance to prepare.
How many people are required to visit a ZPIC site?
ZPIC site visits or audits typically include at least three people. When the auditors arrive, ask for their photographic identification and business cards. They all should have proper photographic identification from their company or agency. They should have business cards, but new employees and people in training sometimes do not. Write down the names, addresses, job titles, and telephone numbers of any person who does not have a business card. We have heard of (but have not confirmed) at least one instance where the inspected office did not verify auditors’ identities and failed the audit for lack of proper security under HIPAA and Medicare conditions of participation.
What happens if you don't update your physical address?
If you have not updated your physical address or you have an incorrect or incomplete address in the Provider Enrollment, Chain, and Ownership System (PECOS), the auditors may go to an invalid address or not be able to find you. Your Medicare billing privileges automatically could be terminated. If your address is incorrect, immediately change it or correct it in PECOS and the National Plan and Provider Enumeration System online.
Who is the communication liaison?
Usually, the communication liaison will be your office manager or practice manager - or you - because the person should know where to obtain all of the documents and information the auditors request. This person should stay with the auditors when they tour and inspect your office. Your attorney should accompany them as well, but he or she probably will not be able to answer most questions about your office or practice.
Do auditors want to interview?
Make sure it is clean and that the chairs are not damaged or torn. The auditors will want to interview virtually every one of your employees while they are there.
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.
Who should be the liaison for an audit?
Ideally, the liaison should be you or your office manager . This liaison will need to know where to find the information that the auditors request. They should be there with the auditors when they inspect the office.
What is RAC audit?
The RAC audits were developed in accordance with the Medicare Modernization Act of 2003. The program reclaims money by reviewing fee-for-service (FFA) claims – a process that has come to be known as a “clawback.”. The RAC audits essentially divide the country into four regions.
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.
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.
You might not be able to avoid a Medicare audit, but you can make sure you're totally prepared to face one. Click here to find out how
Medicare compliance rules for fully credentialed therapists can be more than a bit complicated, so it’s not...
1. There are three major audit-worthy red flags for physical therapists
As you know, Medicare policy is a web of super-confusing rules and regulations. But for PTs, the majority of audits result from one of the following triggers:
2. Sub-par documentation puts you at greater risk for an audit
In addition to the suspect practices listed above, the following mistakes could land you in hot water with Medicare:
3. Certain billing practices increase the likelihood of an audit
Even if your documentation is in tip-top shape, these billing no-nos could arouse Medicare’s suspicions:
4. There are measures you can take to protect your practice
When it comes to avoiding audits, knowledge is power, so make it your mission to educate yourself and your staff on Medicare’s Local and National Coverage Policies.
5. There are different kinds of audits
As this article explains, in 2010 President Obama announced an initiative to reduce the amount of money wasted on improper Medicare payments.
What is UPIC audit?
The Centers for Medicare and Medicaid Services (CMS) created the UPIC audits to identify and stop fraud and abuse in Medicare and Medicaid. The main goal of UPIC is to help CMS: Find fraud, abuse, and waste. Perform regional Medicare and Medicaid data analysis. Complaint resolution.
What is MAC in Medicare?
The Medicare Administrative Contractor (MAC) is in charge of all other responsibilities assigned to the UPIC by the Statement of Work. MAC responsibilities include: Appeals. Claims processing. Customer service. Financial accounting. Medicare Secondary Payer education. Refer suspected fraud and abuse to the UPIC.
Why is it important to have a plan in place?
Having a plan in place will ensure you don’t miss any crucial steps in an audit. It can also help spot any potential errors within your system and correct them before an error occurs.
