The audits focus on ensuring that MAOs don’t game the system and claim back more money than they should, while also seeing to it that they provide optimal levels of care to their patients. Every year, the CMS
Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services, previously known as the Health Care Financing Administration, is a federal agency within the United States Department of Health and Human Services that administers the Medicare program and works in partnership with state government…
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.
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.
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.
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 is the purpose of Medicare audits?
The Medicare Fee for Service (FFS) Recovery Audit Program's mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that ...
What does Medicare look for in an audit?
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 when Medicare audits you?
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.
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.
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 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 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 triggers a RAC audit?
RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare's clinical payment criteria, documentation and billing requirements.
What are the chances of getting audited?
An audit happens when the IRS flags your tax return and reviews it for accuracy. In all, you have about a 0.6% chance of being audited. Things like high income and unusual deductions can increase your risk of getting flagged.
Why do people get audited?
The IRS conducts tax audits to minimize the “tax gap,” or the difference between what the IRS is owed and what the IRS actually receives. Sometimes an IRS audit is random, but the IRS often selects taxpayers based on suspicious activity. We're against subterfuge. But we're also against paying more than you owe.
What happens when you get audited?
However, there's always the possibility that you could face an audit, and, if you're found to have misrepresented your income, tax audit penalties can be serious. Consequences range from stiff fines to criminal charges, and you could be buried under a mountain of paperwork.
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 was the Obama administration's goal in 2010?
In 2010, the Barack Obama administration launched an initiative that sought to reduce the amount of money spent on subpar Medicare payments. Since the initiative, there have been more efforts to reduce payment errors. Generally, here are some of the audit programs in place:
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.
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.
What to do if you are subject to Medicare Advantage audit?
If you are subject to a Medicare Advantage audit, use precision in selecting an attorney to defend you. You’ll need a veteran team with full mastery over the subject to properly get you organized and maintain compliance.
What is Medicare audit playbook?
Essentially, your audit playbook is a rundown of activities that will help you plan the right policies for staying compliant with the Medicare Advantage audits. The playbook will include methods of collecting and logging data, as well as how to best present your information to auditors.
What is the CMS Advantage Audit Guide?
One of the many benefits of the CMS Medicare advantage audit guide is that it provides an opportunity for you to understand the right compliance processes. You can also manage your operations better to ensure compliance and move faster from there.
What is MAO in Medicare?
If a non-contracted healthcare provider is offering services, then the MAO makes a payment under traditional Medicare rules and regulations. This provides an opportunity to question how an MAO can adjudicate a claim under standard Medicare rules, while the MAO’s adjudication system has been developed to address claims.
What is Medicare Advantage?
Medicare Advantage programs are more common these days, with a significant portion of Medicare beneficiaries currently enrolled in different programs. Known commonly as MA plans, the Medicare Advantage programs are issued by Medicare Advantage Organizations (MAOs) —usually, insurance companies.
Why are MAOs attracted to Medicare?
At the same time, MAOs like the programs because they have risk-adjusted payments from Medicare.
Can Medicare audits happen at any time?
The truth about the Medicare Advantage audits is that they can happen at any time. Being prepared isn’t easy, especially since audits take a lot of time and effort. However, by following these tips, you can ensure that audits will never catch you off-guard.
What forms should be included in a nursing home discharge?
Consent forms, medical history questionnaires, histories, physicals, other physicians' orders, all may be a crucial part of the record and should be included. If hospital or nursing home discharge orders or other orders referred the patient to you, obtain these to provide to the auditors.
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.
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.
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.
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.
What does a Recovery Audit Contractor (RAC) do?
RAC's review claims on a post-payment basis. The RAC's detect and correct past improper payments so that CMS and Carriers, FIs, and MACs can implement actions that will prevent future improper payments.
What Topics do RAC's Review?
Stay in the know on proposed and approved topics that RAC's are able to review. These topics will be updated monthly on the RAC reviews topic page and include:
What is the OIG work plan?
The OIG Work Plan. Through ongoing assessments, the OIG prioritizes issues posing a threat to the Medicare Trust Fund. It then allocates resources to conduct audits targeting those priorities in its annual Work Plan, which is updated monthly to address emerging issues.
How far back can RACs audit claims?
RACs may audit claims going back three years from the date of payer reimbursement.
Why is medical auditing important?
Medical auditing performed by the provider organization, or on its behalf, is crucial because it keeps coding and billing errors in check. Audits not only identify incorrect coding, but also prevent incorrect coding from being repeated.
What is CMS in healthcare?
Federal Scrutiny and Compliance Enforcement. Law requires the Centers for Medicare & Medicaid Services (CMS) — the largest payer for healthcare in the U.S. — to protect the taxpayer-sponsored Medicare Trust Fund.
What is medical audit?
Medical auditing is a systematic assessment of performance within a healthcare organization. Almost any element of healthcare can be audited, but most audits look at components of payer reimbursement processes to evaluate compliance with payer guidelines and federal and state regulations. By identifying errors and devising remedial actions ...
Why do auditors use audit software?
Some auditors choose audit software to audit records, print an audit report, and help analyze the data. Keep in mind that computer software does not have the capability to evaluate medical necessity. This is a “thinking” process that requires the auditor to possess a strong background in medical coding.
Why is an audit tool important?
An efficient audit tool is important when auditing the medical record. If the auditor is conducting a review of surgical notes, for example, a surgical audit tool should be used. If the auditor is conducting an E/M audit, the tool needs to reflect the guidelines used by the practitioner.
What is UPIC audit?
UPIC audits are often generated through data analysis or by review of consumer complaints, and most often target specific healthcare providers. Currently, telehealth claims are part of the UPIC targeted audits, as more and more providers have moved to a telehealth platform during the PHE. But in early review, it has been reported by CMS ...
Why are audits at higher risk?
This is why these audits are at higher risk of errors having occurred. Generally, audits reflect a specific date range, and auditors apply appropriate payor rules. The appropriate guideline or regulation may not be applied correctly, or to the applicable time frame, which could reveal an overpayment in error.
What are the rules for telehealth?
The rules applicable to telehealth, supervision, inpatient rehabilitation facilities (IRFs), and nursing homes changed rapidly at the onset of the PHE, as well as “approved providers,” which can perform services that they may not have been authorized to perform before.
When will CMS stop exercising enforcement discretion?
Specifically, CMS stated that: “As states reopen, and given the importance of medical review activities to CMS’s program integrity efforts, CMS expects to discontinue exercising enforcement discretion beginning on Aug. 3, 2020, regardless of the status of the public health emergency .” (Emphasis added.) The CMS announcement was released in ...
Who is Terry Fletcher?
Terry Fletcher, BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMSCS, CMCS, ACS-CA, SCP-CA, QMGC, QMCRC, is a healthcare coding consultant, educator, and auditor with more than 30 years of experience. Terry is a past member of the national advisory board for AAPC, past chair of the AAPCCA, and an AAPC national and regional conference educator. Terry is the author of several coding and reimbursement publications, as well as a practice auditor for multiple specialty practices around the country. Her coding and reimbursement specialties include cardiology, peripheral cardiology, gastroenterology, E&M auditing, orthopedics, general surgery, neurology, interventional radiology, and telehealth/telemedicine. Terry is a member of the ICD10monitor editorial board and a popular panelist on Talk Ten Tuesdays.
