Auditing

What To Do When a Payer Audits You

When a payer audits you the first thing to do is respond to the audit. Do not ignore it; it won’t go away. In the initial stage of the audit, they will probably ask you to send them your notes on approximately 5-10 patients. Either have a health care attorney or yourself send exactly what they want in a timely fashion. Delaying, or not sending the notes, might lead the insurance carrier to think that you are hiding something.

Send nothing more and nothing less than what they ask for.

Was Your Claim Denied as a Duplicate Service?

On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?

First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the claim may be denied as duplicate:

Alphabet Soup for Waste and Fraud Inspectors

The following are some of the acronyms you would need to know when communicating with auditors:

National Correct Coding Initiative (NCCI) Edits: Use of codes that should not occur on the same day, effectively treating the same area twice.

Medically Unlikely Edits (MUE):  Exceeding the anticipated units of service (time spent) for a given HCPCS or CPT code.

Security

How secure is your computer? Do you have a password on your computer? Do you have the automatic log offs turned on? Is your computer encrypted? Are your off-site storage files encrypted?

This document is designed to give some basic information about making your office a little more secure. It is not a substitute for a thorough HIPAA assessment.

However, there are some steps you can take right now to help cut your risk of identity theft, or security breaches. Take steps TODAY!

40-Effect of Beneficiary Agreements Not to Use Medicare Coverage

(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)

(Rev. 194, 09-03-14)

 

Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  

The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contains information about each zone as well as activity and updates in those regions. 

What is a Gap Analysis?

A Gap Analysis is a process by which a practice conducts a baseline assessment of the company's coding, billing, operations, and business practices. The objective of a Gap Analysis is to ensure that the practice is in full compliance with applicable legal and ethical requirements. 

This performance measurement tool is used to determine which actions must be taken in order to bring the entity's practices up to the desired/required level of compliance. 

It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. According to a Forbes article, a health care actuary estimated that private insurers annually “lose perhaps 1 to 1.5 percent in fraud.” Meanwhile, the problem is worse for public insurers. The same actuary estimates that “Medicare and Medicaid may be closer to 10 to 15 percent.” According to the recently released Medicare Fee-for-Service 2013 Improper Payment Rate Report, the improper payment rate increased from 8.5% in 2012 to 10.1% in 2013.

Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 defendants were convicted of health care fraud-related crimes during the year.

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