What should you 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 are the Medicare audit programs?
Generally, here are some of the audit programs in place: 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.
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.
How do Medicare contractors conduct Medicare audits?
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 does a Medicare audit work?
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 entities conduct medical review of claims?
Who conducts the medical reviews? Medicare Fee-for-Service (FFS) reviews are conducted by Medicare Administrative Contractors (MACs), the Supplemental Medical Review Contractor (SMRC), Recovery Audit Contractors (RACs), and others.
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 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 causes 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.
Who reviews individual cases to ensure that medical care services are medically necessary?
Medical InsuranceQuestionAnswerA review of individual cases by a committee to make sure that services are medically necessary and to study how providers use medical care resources is called a(n)utilization review21 more rows
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.
Who performs RAC audits?
There are currently three firms that administer RAC audits, according to CMS' website: Performant Recovery Inc., Cotiviti LLC and HMS Federal Solutions, and the company that comes calling depends on your agency's geographic region.
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 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 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.