Full Answer
What is a retrospective audit and how do I conduct one?
In a retrospective audit, you’ll need the superbill/charge ticket, patient chart, claim form or billing record (to validate what was submitted), and the explanation of benefits (EOB) or Remittance Advice — for each patient encounter.
What triggers Medicare to audit Pts?
As you know, Medicare policy is a web of super-confusing rules and regulations. But for PTs, the majority of audits result from one of the following triggers: Excessive (i.e., above the norm) use of the KX modifier, which signals an automatic exception to the therapy cap on the basis of medical necessity
What is a medical record audit?
Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by physician documentation. Once areas of weakness are revealed through an audit, you can present the audit findings and identify opportunities for training in your health care organization.
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.
Who performs Medicare audits?
In the case of physician practices, audits are usually performed by Part B carriers. One of the more common methods used by Medicare to determine that an audit is appropriate is through the identification of billing patterns.
What is retrospective audit?
A retrospective audit is a cost containment mechanism that health insurers use to determine whether overpayments on claims have been made to a particular physician practice.
What does a Medicare auditor do?
As a Medicare auditor, you review health insurance information and documentation to ensure accuracy and locate errors or discrepancies. Your duties include reviewing billing and claims processes to ensure healthcare and medical service providers abide by Medicare regulations.
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...
How do you conduct an audit in healthcare?
CHOOSE A CLINICAL AUDIT TOPIC. Your topic should be chosen systematically. ... FORM A PROJECT TEAM. ... SET THE AIM, OBJECTIVES AND STANDARDS. ... ETHICS & ENGAGEMENT. ... SELECT AN AUDIT SAMPLE. ... PLAN AND CARRY OUT DATA COLLECTION. ... ANALYSE THE DATA. ... PRESENT THE FINDINGS.More items...
How do you conduct a retrospective chart review?
Table 1.Create well-defined, clearly articulated research questions.Consider sampling questions a priori.Operationalize variables included in retrospective chart review.Train and monitor data abstractors.Develop and use standardized data abstraction forms.Create a data abstraction procedure manual.More items...
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.
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 is a CMS mock audit?
A mock program audit helps plans prepare for an actual CMS audit by: Identifying resources. Uncovering gaps in processes. Enhancing communication with first tier, downstream and related entities (FDRs) Including evaluating their ability to assist in audit activities, such as compiling universes.
What is the difference between Mac and RAC?
MAC audits are powerful and intrusive procedures that have the potential to lead to serious federal charges for healthcare entities. A Recovery Audit Contractor (“RAC”) reviews claims and identifies overpayments from Medicare so that CMS and other auditors are able to prevent improper payments in the future.
How many years back can Medicare audit?
three yearsMedicare 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.
What are the different types of audits in healthcare?
There are two main types of healthcare audits that providers face: internal and external. External audits can be broken down further into government and commercial insurance audits. From there, government audits can be broken down even further into Medicare, or Recovery Audits and Medicaid audits.
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.
Auditors
CMS contracts with Medicare Contractors to conduct pre- and post-payment audits of providers.
Audits
The pre- and post-payment audits are generally categorized based upon how the Medicare Contractors select the claims (i.e., whether the claims are audited prior to or after payment by Medicare is made).
Redetermination by a MAC
The first level of appeal is the redetermination following notice of the initial determination. A party to the initial determination has 120 days to request that the MAC perform a redetermination of the claim (s) regardless of the amount in controversy.
Reconsideration by a QIC
Parties to the redetermination have 180 days to request reconsideration from a Qualified Independent Contractor (QIC) from the date of receipt of the notice of redetermination. 15 It is important to note, CMS will begin recouping overpayments beginning after the 60th day from the redetermination decision. 16
Hearing by an ALJ or review by attorney adjudicator at OMHA
Parties to an unfavorable reconsideration decision (or if the QIC's adjudication period has elapsed) may request a hearing before an administrative law judge (ALJ) if the amount in controversy of the claim is at least $160 for calendar year 2018 (claims can be aggregated to meet this threshold).
Review by Medicare Appeals Board
A provider may appeal ALJ's decision to the Department Appeals Board (DAB) Medicare Appeals Council (DAB/MAC) within 60 calendar days of the ALJ's decision. 19 No new evidence will be considered at this level absent good cause and there is no hearing requirement (at discretion of Council).
Judicial Review in U.S. District Court
Providers may appeal DAB/MAC decisions to the federal District Court within 60 days of the DAB/MAC decision if the amount in controversy is at least $1,600. 20 Providers may also appeal to District Court if the DAB/MAC fails to rule within its required timeframe.
What is the role of a medical auditor?
Among different types of medical audits, the auditor’s role remains the same: review healthcare providers’ policies and procedures to ensure compliance with federal, state, and payer regulations. But questions invariably arise, given the assorted methodologies of auditing and the myriad requirements that define compliant billing activity.
What is prospective audit?
Prospective audits: The prospective audit, also called a pre-payment audit, is performed prior to claim submission. Typically, the billing record (charge ticket or superbill) is obtained, along with the chart documentation and any supporting labs, medication sheets, problem lists, etc.
What is an IRO audit?
Select an Independent Review Organization (IRO) An IRO acts as a third-party medical review resource that provides objective, unbiased audits and reports. An auditor working as an IRO needs to understand the CIA of their client, including specific terms that may affect the auditing or reporting of the IRO.
What is a focused audit?
A focused audit may concentrate on one type of service to determine compliance, such as new patient visits, established patient visits, consultations, or nursing home visits. If your organization employs nonphysician practitioners, you might conduct an audit to verify compliance with incident-to rules.
What is an automated review?
Automated review occurs when a recovery auditor makes a claim determination at the system level without a human review of the medical record. Complex review occurs when a recovery auditor makes a claim determination using human review of the medical record or other required documentation.
What is the process of examining the medical record, verifying information, and gathering baseline information to identify risk areas?
Auditing is the process of examining the medical record, verifying information, and gathering baseline information to identify risk areas. Monitoring is the ongoing process of reviewing coding practices and the adequacy of the documentation and code selection.
What is external audit?
An external audit, on the other hand, delivers invaluable objectivity. Whether you manage a hospice or a home health agency, a solo physician practice, or a large university medical center, your organization benefits from another set of eyes. You can’t fix what you don’t know is broken.
Why did health insurance companies use the skillset?
The skillset gained popularity within the health insurance industry, mainly due to growing research about medical necessity, misuse, and overutilization of services. Therefore, health plans began to review claims for medical necessity, and the hospital length of stay (LOS). To contain costs, some health plans required the physician to certify ...
What is a prospective utilization review?
Prospective review includes the review of medical necessity for the performance of services or scheduled procedures before admission. Concurrent reviews include a review of medical necessity decisions made while the patient is currently in ...
Why was utilization review introduced?
Utilization review, as a process, was introduced in the 1960s to reduce overutilization of resources and identify waste.
How has healthcare changed in the last 100 years?
Healthcare has changed drastically in the last 100 years. Healthcare costs continue to rise, quality of care is questioned, and chronic diseases are evident now more than ever before. These challenges must be addressed by the industry, and effective solutions are a must.
What is retrospective audit?
The inquirer asks “whether the [Insurance Department] is aware of any statute, regulation or rule that would give a health insurer (including health maintenance organizations regulated under Article 44 of the Public Health Law) the authority to conduct a retrospective audit of a non-participating health care provider.” By “retrospective audit” the inquirer refers to “a request by a health insurer to a health care provider to supply the insurer with medical records to substantiate past payment of the provider’s claims for health care services, where any alleged overpayment identified by the insurer would result in a demand by the insurer for repayment of the overpayment.”
What is the weighty obligation under 11 NYCRR Part 86?
For instance, an insurer and an HMO have a weighty obligation under 11 NYCRR Part 86, under which it is not material whether a health care provider is a participating provider or not, to discover and report to the Department evidence of insurance fraud, including a duty to conduct fraud audits.
CMS Integrity Program — Audits and Auditors
Auditors
- CMS contracts with Medicare Contractors to conduct pre- andpost-payment audits of providers. These audits may result inadministrative actions to require repayment of overpayments;suspension of payment to providers; revocation of Medicare billingprivileges; referral to the OIG and/or DOJ to investigate potentialfraud, waste, and abuse issues; and/or...
Audits
- The pre- and post-payment audits are generally categorized basedupon how the Medicare Contractors select the claims (i.e., whetherthe claims are audited prior to or after payment by Medicare ismade). Claims are also identified based on whether they areselected randomly or based on a specific provider, and whether theclaims require a clinical review, deeming whether t…
The Appeals Process — Parts A and B
- Medicare Part A providers have a separate appeals process fordisputes arising from cost reports through the ProviderReimbursement Review Board (PRRB) at CMS. The Medicare Part A and Bclaims appeal process covers pre-payment and post-payment claimdisputes for Part A providers and Part B suppliers, includingDurable Medical Equipment, Prosthetics, Orthotics, and Supplies(…
Redetermination by A Mac
- The first level of appeal is the redetermination followingnotice of the initial determination. A party to the initialdetermination has 120 days to request that the MAC perform aredetermination of the claim(s) regardless of the amount incontroversy.12 If the initial determination found anoverpayment, CMS will begin recouping the amounts beginning 41 daysfollowing the demand.…
Reconsideration by A QIC
- Parties to the redetermination have 180 days to requestreconsideration from a Qualified Independent Contractor (QIC) fromthe date of receipt of the notice of redetermination.15It is important to note, CMS will begin recouping overpaymentsbeginning after the 60th day from the redeterminationdecision.16 This is the last opportunity where all supporting evidence willbe acc…
Hearing by An ALJ Or Review by Attorney Adjudicator Atomha
- Parties to an unfavorable reconsideration decision (or if theQIC's adjudication period has elapsed) may request a hearingbefore an administrative law judge (ALJ) if the amount incontroversy of the claim is at least $160 for calendar year 2018(claims can be aggregated to meet this threshold).17Requests must be filed within 60 calendar days of receipt of theQIC's reconsiderati…
Review by Medicare Appeals Board
- A provider may appeal ALJ's decision to the DepartmentAppeals Board (DAB) Medicare Appeals Council (DAB/MAC) within 60calendar days of the ALJ's decision.19 No newevidence will be considered at this level absent good cause andthere is no hearing requirement (at discretion of Council). TheDAB/MAC reviews the decision of the ALJ on the records denovo, which allows the …
Judicial Review in U.S. District Court
- Providers may appeal DAB/MAC decisions to the federal DistrictCourt within 60 days of the DAB/MAC decision if the amount incontroversy is at least $1,600.20Providers may alsoappeal to District Court if the DAB/MAC fails to rule within itsrequired timeframe. The venue for the claim will either be in theDistrict of Columbia or the provider's home district. The HHSSecretary's findin…
Strategies For Addressing Audits and Appeals
- In light of the frustrating situation with audits and the appealbacklog, we suggest the following strategies to shape the bestresponse: 1. Before the demand, develop policiesfor dealing with audit requests, including which department and jobtitle is responsible for handling the request, when to involvecounsel, and to use subject-matter experts from the start. 2. After the demand, r…