5 Tips to Avoid CMS Audits
- Prevent Billing and Coding Mistakes. As a physician, payers trust you to provide medically necessary, cost-effective,...
- Provide Accurate Documentation. When in doubt, document. Because there are multiple systems that could be involved in an...
- Perform a Self-Audit. Perform your own random mock audits based on the same criteria as a Medicare...
Full Answer
How can I protect my practice from Medicare audits?
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.
Are You at risk of going through a Medicare audit?
If you treat Medicare patients, then you probably already know that there’s an ever-present threat of going through a grueling audit that could put you and your entire practice in trouble. In fact, this threat could be the riskiest part – other than having to continuously browse the Medicare guide – of treating Medicare patients.
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.
Do I need a lawyer for a Medicare audit?
You have the right for an attorney to be present during the Medicare audit. This is especially true if it’s the RAC audit, as it’s usually the most common—and potentially the most damaging. Get in touch with your attorney and ensure that he or she is there.
How do you survive a Medicare audit?
5 things you need to know to survive a Medicare auditBecome familiar with what common factors may trigger an audit by the MAC. ... Know what to expect in both prepayment and post-payment reviews. ... Accurate medical documentation and constant training for medics and billing staff. ... Appeal the results.More items...•
What triggers Medicare audits?
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 do Medicare auditors look for?
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 happens if you fail a Medicare audit?
Failure to comply with CMS requirements or cooperate during an audit could result in the provider being excluded from providing services through Medicare or Medicaid.
Are Medicare audits random?
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.
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 are the types of Medicare audits?
There are mainly three types of audits — Recovery Audit Contractor (RAC) audits, Certified Error Rate Testing (CERT) audits and Probe audits. Mistakes in medical documentation, coding and billing can rouse Medicare's suspicion during audits, which can lead to claim denials.
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.
What are CMS penalties?
A CMP is a monetary penalty the Centers for Medicare & Medicaid Services (CMS) may impose against nursing homes for either the number of days or for each instance a nursing home is not in substantial compliance with one or more Medicare and Medicaid participation requirements for long-term care facilities.
What are Medicare sanctions?
Any individual or organisation which is excluded from federal healthcare programs is said to have been “sanctioned”. Sanctioned individuals and entities are barred from participating in federal healthcare programs such as Medicare and Medicaid.
Types of audits
Healthcare providers may be subject to different types of audits, each requiring different approaches. Private commercial payers may conduct informal reviews of a few claims or seek formal review of many claims.
California Healthcare Audit Lawyers
For help with payer audits and other healthcare business matters in Los Angeles and California statewide, call the Law Offices of Art Kalantar in Beverly Hills at 310-773-0001 for a free initial consultation.
Where does Medicare audit occur?
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 happens if your Medicare billing address isn't correct?
Eventually, they will terminate your Medicare billing practices. If the address isn’t correct, be sure to change it immediately. Head to the PECOS portal and make the necessary adjustments.
What to do if your PECOS address isn't correct?
If the address isn’t correct, be sure to change it immediately. Head to the PECOS portal and make the necessary adjustments.
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.
Can Medicare reimbursement go through if you have a fraudulent claim?
Note that if you comply, but your documentation is inadequate to support what you have billed, your reimbursement claim won’t go through. In addition to this, if the audit uncovers any perceived fraudulent activity, the Medicare Administrative Contractor (MAC) will take your case up for additional investigation.
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.
How to avoid Medicare audits?
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. Seek out Medicare-related CEU courses, or sign up for Medicare compliance training through the PT Compliance Group or Gawenda Seminars (also be sure to check out the other educational resources these organizations provide). Additionally, you should have a compliance plan in place—headed up by your office’s designated compliance officer—to ensure that all staff members can recognize potential compliance issues and to develop processes and procedures for dealing with misconduct. The plan should:
What do you need to know about Medicare audits?
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.
How often are CERT audits conducted?
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 happens if you fail to comply with a federal investigation?
If you fail to comply, you will not receive reimbursement for the claim.
Pre-Emptive Counsel & Compliance
Reporting Overpayments
- In addition to establishing sound billing and administrative practices, providers should also focus on creating policies for proactively identifying overpayments and promptly reporting them. By law, health care providers must report overpayments and make arrangements to return them within 60 days from when they are identified. Pro-active identification and handling of Medicare overpaym…
Discuss Your Practice & Compliance Issues During A Consultation
- While audits and appeals may be a cost of doing business in the health care space, providers can take viable steps to reduce the likelihood of an audit. From evaluating practices to ensure claims are appropriately billed, refining those practices accordingly, and establishing plans and policies to respond to any audit, providers can increase chance...