Medicare Compliance & Reimbursement

This year, hundreds of practices will get the news that no one wants -- Medicare is reviewing their claims as part of an audit.

Today we've got five ways for you to stave off audits -- and when necessary, prepare for them -- that can help you get on the right track.

1. Keep up with Medicare regs. Medical practices are often too busy to stay on top of all of their carriers' many policy changes, which can spell trouble from a compliance standpoint. If you fail to keep up with your payer's requirements, you could be coding incorrectly, and you might end up being an audit target.

For example: During a recent recovery in Connecticut, three separate providers made identical errors that caused Medicare to accuse them of overbilling a particular service.

"It would be surprising to see the same deliberate fraudulent overbilling in three different provider systems, which leads me to believe there's a good chance that the rules changed and the practices just weren't aware of it," says David C. Harlow, Esq., of The Harlow Group in Newton, MA.

2. Ensure that your documentation is correct. In some cases, the physician may circle a level of service on his claim form that he performed, but he didn't document properly to justify the code.

"I have shadowed physicians in the past while they've treated patients, and the key thing I noted was that many times, doctors are doing all of this work but fail to document the services they did," said Annette Grady, CPC, CPC-H, CPC-P, CCS-P, OS, an independent healthcare advisor and instructor, during her May 20 Coding Institute audioconference, Everything You Need to Know About Responding to a Chart Review. "The sad part about that is I knew the work was performed, but the documentation didn't support that the service was provided," she says.

"If you end up in an audit and you're trying to make excuses for documentation gaps, you're fighting a losing battle," Harlow says. "The goal is to have your documentation in good shape up front. It's not only complete documentation that you need -- it's also accurate documentation," Harlow says.

3. Find out why you're being audited. If an auditor contacts your practice and requests a meeting to discuss your records, ask why.

"It makes sense to try and get a handle on exactly what sort of information they may be looking for," Harlow says. "It is appropriate to ask, 'What is the scope of the audit you're doing? What are you looking for? Is this purely post-payment review, or is there another area that you're looking at?'" Harlow says.

If there's a chance that your practice is the target of a criminal investigation, you should ask your attorney to come to the audit, Harlow says.

4. Gather your documentation. Often, the auditor simply wants to review your documentation to ensure that it meets the service you billed. "For instance, an audit was done in 2003 where the government found that about 35 percent of claims including modifiers 25 and 59 didn't support the service," Grady says. "So now they sometimes request documentation during a prepayment review to ensure that those modifiers have been reported appropriately."

5. Keep a record of what the auditors review. "If the auditors take copies of your documentation, you should get a set of copies of the same materials so you know what they've taken with them to examine, whether it's paper or electronic copies," Harlow says. "That way, you can huddle with advisors later to ensure that everything is complete and accurate." If you find that any of the information that the auditors took with them requires further explanation, "do so proactively, rather than waiting for them to ask," Harlow says.