Medical Audit: How to Avoid Problems Before They Occur
Never forget that each medical practice is subject to medical record audits. Hearing that word practices, start to worry and panic, dwelling on the painstaking, laborious process ahead of them. However, the audit does not need to be difficult or time-consuming. If you are doing your due diligence in running a successful care coordination program, you will get through it easily. Moreover, working with professionals will save you a lot of hassle.
The mission of medical audit is to identify and correct improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to beneficiaries and the identification of underpayments to providers.
Recently, a plurality of clients has turned to us, looking for the help of a certified medical audit specialist when faced with difficulties in auditing by Cotiviti. It is auditing not only straight Medicare but Medicare Advantage and Medicaid HMOs and is engaged in the inspection in three regions.
The most reviewable area of healthcare targeted by payers now is DME. And if you drill down to the improper payment rate for DME, you will find that DME's incorrect payment rate is a staggering 70%.
DME suppliers continue to be plagued by documentation challenges because it is hard for them to demonstrate medical necessity without reliance on others. Physicians and other third-party care providers should examine patients and only then order DME. Unfortunately, some of these providers often do not correctly document the basis for their orders in the medical records because most DME products carry little risk, are easily obtained, and typically do not require much follow-up. New providers encounter an incredibly complex set of federal rules and regulations because of the DME market’s relative ease of entry. The results are billing issues and errors, often associated with unknowledgeable or uncooperative providers. Several unscrupulous suppliers take advantage of federal programs for which auditors usually only scrutinize claim submissions after reimbursements have already been made. That is too late to prevent improper payments. With continued growth and demand for DME, the fraud-and-abuse enforcement activities related to it continue to grow too. Therein lies the reason why it is no longer a question of whether a DME supplier will be investigated but rather when it will happen.
We identify the following elements essential to an effective compliance program:
Standards and Procedures. Every practice must have written policies, procedures, and standards of conduct that articulate its commitment to comply with all applicable Federal and State standards.
High-Level Oversight and Delegation of Authority. Twice a year, you should seek professional help for internal audits.
Employee Training. You need to make sure that your employees are provided with effective training and education to keep up-to-date with the new rules and comply with all requirements.
Communication. Effective lines of communication must be established between the auditor and the practice's employees.
Monitoring and Auditing. Every practice must have taken reasonable steps to achieve compliance with its standards by utilizing reasonably designed monitoring and auditing systems.
Enforcement and Disciplinary Mechanisms. Standards must be enforced through well-publicized disciplinary policies.
Corrective Actions and Prevention. If an offense has been detected, you must take reasonable steps to respond and develop corrective action initiatives, including specific reporting requirements.
We want to remind you that WCH has a professional team of auditors who assist rather than control your practice. Let us analyze your charts before insurance will. It will help you to stay safe and save your money.
Learn more on https://wchsb.com/medical-auditing/