Medicare will use a method that looks at billing patterns to start the process and determine if they need a more in-depth audit of that physician. All information is now stored electronically, so that makes it incredibly easy for auditors to pick out physicians whose billing patterns may be much higher than other doctors for certain procedures.
How do Medicare Audit Contractors review audiologists and speech pathologists?
As policymakers consider legislative and regulatory action to curb fraud, waste, and abuse, claims and services by audiologists and speech-language pathologists are subject to review by one or several audit contractors. There are several types of Medicare contractors with the responsibility of auditing records, claims, and payments.
What is the focus of a Medicare audit?
The focus of the reviews may include, but is not limited to, vulnerabilities identified by analysis of CMS data, the CERT program, professional organizations, and federal oversight agencies. Medicare contractors with the responsibility to audit are given the same guidelines regarding the type of review and reasons to deny.
Do physical therapists get audited by Medicare?
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. The Medicare policy generally contains myriad regulations and rules. However, for physical therapists, most audits generally come from the following red flags:
Can too many CPT claims cause a Medicare 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. Having too many claims for level five CPT codes might, for example, cause you to be audited.
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 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.
What triggers a 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 does it mean when a doctor gets audited?
If the doctor believes that the claims are false, they may have the opportunity to prove so with their own audit. This can help support them and show that the insurer's claims are not backed up with evidence. An audit can reveal costs that the doctor should be aware of.
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 ...
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.
Why would an insurance carrier want to perform an audit?
Audits, whether from the Centers for Medicare and Medicaid Services or from a private insurance company, aim to root out fraud, abuse, and waste in the healthcare system. However, audits also help to encourage practitioners to foster proper medical billing practices and maintain compliance with laws.
What are the 3 types of audits?
Key Takeaways. There are three main types of audits: external audits, internal audits, and Internal Revenue Service (IRS) audits. External audits are commonly performed by Certified Public Accounting (CPA) firms and result in an auditor's opinion which is included in the audit report.
What does an audit look for?
An audit examines your business's financial records to verify they are accurate. This is done through a systematic review of your transactions. Audits look at things like your financial statements and accounting books for small business. Many businesses have routine audits once per year.
How long is an audit cycle?
Audits are typically scheduled for three months from beginning to end, which includes four weeks of planning, four weeks of fieldwork and four weeks of compiling the audit report. The auditors are generally working on multiple projects in addition to your audit.
What does audit mean in medical terms?
Clinical (or medical) audits are part of the continuous quality improvement process that focus on specific issues or aspects of health care and clinical practice. They consist of measuring a clinical outcome or a process, against well-defined standards set on the principles of evidence-based medicine.
Why are medical audits important?
Clinical audit is a way to find out if healthcare is being provided in line with standards and lets care providers and patients know where their service is doing well, and where there could be improvements.
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.
What is Medicare audit?
There are several types of Medicare contractors with the responsibility of auditing records, claims, and payments . Each type of contractor may use different methods to conduct audits, but they must all abide by overarching Medicare guidelines for medical review, denials, appeals, and payment recovery, as set forth by the Centers for Medicare and Medicaid Services (CMS).
How long does it take to get a QIC reconsideration?
If the provider disagrees with the redetermination results, the provider may request in writing, within 180 days, a reconsideration performed by a QIC. A copy of the RA and any other useful documentation should be sent with the reconsideration request. The QIC reconsideration process includes an independent review of the determination and redetermination and may include review by a panel of physicians or other related health care professionals. A minimum monetary threshold is not required to request reconsideration. Reconsideration request forms are available on the Medicare administrative contractors' websites.
What is postpayment review?
Postpayment review may result in no change to the initial payment to the provider or may result in a "revised determination" that would require the provider to pay back monies for services determined to be "not reasonable or necessary.".
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 does "outlier" mean in Medicare?
1. Your billing practices make you an outlier from your peers. When I think of the term “outlier,” it conjures up images of James Dean perched on a motorcycle in a leather jacket. While Dean’s brand of cool nonconformity made him a star, Medicare sees nonconformists in a different—and much less flattering—light.
What happens if your medical documentation is not documented?
If it’s lacking, it could leave you in hot water with Medicare auditors.
Why is it important to show CMS that you're not just a rebel without a cause?
If you suspect that your billing practices are making you stick out, it’s important to show CMS that you’re not just a rebel without a cause. For example, if your claims are returning higher reimbursements compared to your peers, make sure your documentation supports your code choices.
Do questionable billing practices catch up with you?
No matter how fast you are, questionable billing practices will always catch up with you. If and when they do, you better be ready to defend yourself with defensible documentation. With a healthy dose of vigilance—and the right tools to keep your documentation up to snuff—you’ll be ready for anything CMS throws at you.
Is medical necessity a hot button issue?
Medical necessity has always been a hot-button issue in the Medicare sphere, and that’s especially true this year. Thanks in part to the terms of the Jimmo v. Sebelius settlement, Medicare has made great strides in clarifying which services it deems medically necessary—particularly with respect to maintenance care. That’s good news for therapists, but as I mentioned in this post on the topic, it also means that “proving medical necessity could become an even larger issue for rehab therapists as charts come under increased scrutiny.”
Can a CBR be audited?
While receipt of a CBR doesn’t always mean you’ll be audited, it can often be a precursor to an audit if your documentation does not support your billing practices. So, if your billing practices have room for improvement, be sure to use the feedback in the CBR to make the appropriate adjustments to your process.
Does CMS expect you to stay up to date?
And let’s face it: keeping up with those changes can be a challenge. But, CMS expects you to stay up to date, and failing to do so could lead to some major red flags. Common code-related warning signs include:
What is PIM in Medicare?
As set out under Section 4.1 of the Medicare Program Integrity Manual (PIM), CMS relies heavily on UPICs and other contractors to identify and refer suspected cases of fraud to law enforcement for further investigation:
What is a UPIC response?
Responding to a Request for Records Sent by a UPIC: UPICs are expected to adhere to applicable Medicare coverage guidelines. Nevertheless, a UPIC’s interpretation and application of these coverage requirements may greatly differ from your understanding of the same provisions.
Do UPICs have Medicare coverage?
UPICs are expected to adhere to applicable Medicare coverage guidelines. Nevertheless, a UPIC’s interpretation and application of these coverage requirements may greatly differ from your understanding of the same provisions. In recent years, these CMS program integrity contractors have been aggressively pursuing a wide variety of enforcement actions.