Avoiding a Medicare Audit
The Federal Government has approved millions of dollars dedicated to auditing resources to ensure providers are being reimbursed properly for the products and services they provide to Medicare beneficiaries.
A central driver for the government's heightened support is rooted in the increased number of policies, procedures and regulations healthcare providers are required to follow and stay knowledgeable on as change occurs.
According to the Centers for Medicare and Medicaid Services (CMS), the Federal Government estimates that about 12.1% of all Medicare Fee-For-Service (FFS) claim payments are improper. CMS began several initiatives to prevent or identify improper payments before claims are processed as well as to identify and recover improper payments after paying a claim. The overall goal is to reduce improper payments by identifying and addressing coverage, medical documentation, coding billing error for all provider types.
To help guide your decision making, I recommend reviewing these common areas of concern:
- Copy and Paste Documentation: It is acceptable to use templates, but your documentation must be patient specific.
- Up-coding: Physicians who over-code evaluation and management services (E&M) relative to their peers remain at a greater risk of audit. Audit your providers to make sure that he/she understands all the elements needed for E&M codes. Many times, the medical decision making is documented but the history, review of systems, or exam, is lacking to support a higher level charge.
- Medical Necessity: Just because a high level history and exam was done, was it necessary? Would most providers feel compelled to do this same level of exam to provide necessary care?
- Template Issues: Talk to your biller/provider. Templates can and should be changed as needed.
- Smart-Phrases: Coders and providers need to remember that Smart-Phrases can and should be changed if needed. Avoidance is the key. It is extremely costly to defend yourself, even when you are billing/coding correct.
Read the Department of Health and Human Services' Medicare Claims Review Programs overview for more information.