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.
Full Answer
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.
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.
What does a healthcare audit look for?
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.
What is medical auditing?
What is Medical Auditing? - AAPC Home > Resources > Hot Topics > Medical Auditing > What is Medical Auditing? What Is Medical Auditing? Medical auditing is a systematic assessment of performance within a healthcare organization.
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 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 are the two types of Medicare audits?
Types of Medicare AuditsRecovery Audit Contractor (RAC) Audits.The Certified Error Rate Testing (CERT) Audits.Probe Audits.Check the address on the letter and ensure that it is the address of your practice.Make contact with the auditors.Keep copies of all transmitted documents to the auditors.More items...
What happens if you fail a CMS audit?
Civil monetary penalties (CMPs) of up to $1,000,000 as adjusted annually2 may be imposed on reporting entities if they fail to report information in a timely, accurate, or complete manner.
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.
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 ...
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 far back can CMS audit claims?
Recovery Auditors who choose to review a provider using their Adjusted ADR limit must review under a 6-month look-back period, based on the claim paid date. Recovery Auditors who choose to review a provider using their 0.5% baseline annual ADR limit may review under a 3-year look-back period, per CMS approval.
How far back can Medicare recoup payments?
(1) Medicare contractors can begin recoupment no earlier than 41 days from the date of the initial overpayment demand but shall cease recoupment of the overpayment in question, upon receipt of a timely and valid request for a redetermination of an overpayment.
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 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 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.
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.
What happens if your medical documentation is not documented?
If it’s lacking, it could leave you in hot water with Medicare auditors.
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.
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.
Can a billing or coding specialist help you?
In many cases, a billing or coding specialist can help you catch these errors before you ship your claims off to Medicare. But, even if you employ a licensed coder, it’s always a good idea to educate yourself on the ins and outs of various code changes and modifier rules.
Is it acceptable to bill Medicare for services rendered by a student?
(For example, it’s never acceptable to bill Medicare for services rendered by a student.) Subscribing to educational resources like CMS email updates, APTA news releases, and the WebPT Blog can help you stay in the know on Medicare rules and compliance changes. (If you’re wondering whether your billing knowledge is up to snuff, be sure to take our billing blunders quiz .) Additionally, if your EMR platform features built-in compliance alerts and safeguards, it can help you catch smaller errors such as underbilling and 8-minute rule noncompliance.
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 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 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.
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.
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 Medicare audit?
A medicare audit is not something to take lightly and everyone must understand how important it is to comply with. Gather all requested information and documents. The CMS will notify your organization of submissions under review and which supporting documents are needed.
How old can Medicare audit claims?
Medicare can look at claims as old as 4 years, so review as many claims as possible and look for mistakes. If you have a plan in place to correct the mistakes you discovered, it will save time during the audit.
What is a point person in Medicare audit?
Your point person is critical in the auditing process – he or she must be knowledgeable and well-informed on medicare billing practices and your own internal billing systems. A Medicare audit is not something that should be taken lightly, but it can be prepared for ahead of time by instituting best practices.
What is the phase 1 of audit?
Phase 1 – Audit Engagement and Universe Submission. Phase 2 – Audit Field Work. Phase 3 – Audit Reporting. Phase 4 – Audit Validation and Close Out. The Audit Engagement and Universe Submission phase involves formally notifying the organization that the audit will indeed take place, as well as a request for pertinent materials.
What is the audit report phase?
The Audit Reporting phase includes CMS classification of non-compliance and an audit score, a notice of immediate corrective action required (ICAR), a corrective action plan (CAP) from the organization, and draft and final audit reports from CMS.