Practice Management Alert

And Medicare isn't the only carrier that can get you in trouble

Do you ever wonder what happens behind the scenes to spark a federal audit and peg a practice for alleged billing misconduct?

Experts constantly warn about the threat of an HHS Office of Inspector General (OIG) audit, but many billers don't know how it all starts. Here are the need-to-know audit facts:
 
- The Centers for Medicare and Medicaid Services (CMS) and other regulatory agencies have been tracking code utilization data for many years, says Annette Grady, CPC, CPC-H, a healthcare consultant with Eide Bailly LLP in Bismarck, N.D. Carriers continuously monitor this data to ensure they're not paying out more than they should. Depending on the focus, carriers may monitor overutilization of procedures compared to a provider's peers, level of E/M services, or procedures that certain specialties would never perform, says Grady, who also sits on the National Advisory Board for the American Academy of Professional Coders.

- Medicare is not the only carrier to flag practices for suspicious billing patterns. Grady has seen Blue Cross Blue Shield place providers under what the carrier calls "focus review," and she's also seen workers' compensation carriers confront physicians for alleged overutilization of procedure codes.
 
- The bottom line is that if your practice's billing data don't mesh with the statistical averages, a carrier can flag you for suspicious billing and audit the records in question and/or report its findings to the OIG. In this case, the OIG will then pursue an audit of your practice.
 
- Carriers also analyze utilization data so they can place limits on some services that are increasing insurance industry costs. For example, "currently, colonoscopy is a very popular procedure, and due to the higher rate of utilization over the past few years," there are now specific coverage policies that dictate which patients are eligible, Grady says.