How to Survive and Win an Audit; by an Insurance company and or Governmental agency like Medicaid/Medicare.
 |
| Add caption |
In the early 90’s I recall a telephone conversation I had with a claims reviewer from New York State. I called about a pended claim submitted for extraction and incision and drainage, and the reviewer asked me my custom and billing practices. I thought the question to be odd, especially because he was implying that the procedures may be unnecessary and “automatically billed” together instinctively, devoid of clinical decision making and cerebral thought.
Long before this, while practicing as a licensed hygienist, I understood the importance of possessing a license and take that charge seriously. Explaining to my colleague on the other line that my custom was to determine what was necessary to treat the patient, not the bottom line. The risk of losing my license for billing an incision and drainage, a $17 fee, is not only unnecessary it’s unethical, illegal and absurd! Even if I had performed ten extractions on ten different people, no amount of money would allow me or my conscious to do such a stupid thing. The loss of one’s license, and more importantly, the loss of trust and the stain on my name and reputation would be irreparable. Needless to say I was paid for my treatment and learned that insurance companies make decisions based on their own needs.
 |
| Don't panic. Appoint a responsible individual to handle the audit or personally handle it yourself. |
How to avoid and win an audit by an Insurance company or Governmental Agency.
• All Doctors/Providers and insurance billing staff need to attend at least one full coding course by Medicare and or by the ADA or Specialty Association. The course should include how to complete an ADA form and a HCFA1500 form and their requisites.• Doctor/Providers should have knowledge of proper and accurate Diagnostic (ICD-10) and Treatment codes (CDT/CPT) and Modifier codes.
• Providers should be knowledgeable of the rules for billing and assurance that claims are clean and released for payment without errors.
• Maintain accurate records including referrals into and out of the office. Inclusive of dates, radiographs, labs, etc.
• The Doctor is ultimately responsible for maintaining an accurate patient record.
• Know your Insurance contract
• Audits are an avenue for these agencies to take a step into your office and monitor the function of your practice.
• Consider Creating a Compliance Program
• Consider consulting an attorney.
What do you do if you are Audited?
• This is a task for a senior employee, this process must be monitored and responded to properly and within the time frame allotted.• Create a Folder on your computer desktop and or use a new clean pad of paper and record the name and contact information of the Investigator and investigative agency.
• Keep a meticulous record of this process to include the dates and times with whom you speak.
• Maintain for reference the Insurance company documents in a binder which will include: your contract, other important written correspondence including changes to your contract. Listing of Codes they recognize for utilization. Fee schedules.
• Use the Appeal process to prove your case or show that this was an outlying single error, and not a custom of practice.
What if the audit finds you have breached the standards or their Contract?
• Depending on the type of Audit: (RAC) Recovery Audit Contractors with CMS, UPIC, CERT, PERM.• What a provider my call an error may be considered intentional by an agency. At this point you have an opportunity to do your own internal audit to determine what happened and prove your innocence or mistake.
• Insurance companies and government agencies will apply a mathematical formula of occurrence and determine refund amounts due based on this.
What may happen if you are found to have breached their audit?
• Loss of participation status• Repayment of funds if the breach was related to payments received with interest added
• Restitution
• Penalties
• Criminal charges with jail time
• Loss of license
I realize providers have limited time, however I strongly recommend attending a full coding course that includes Medicare and Medicaid (CMS) Centers for Medicaid and Medicare rules which are ultimately adopted by commercial health insurance carriers. Being aware of the process makes it less likely a coding error or misstep will occur.
My Experience
Many years ago I received a letter from the State Medicaid office regarding several cases receiving similar kinds of treatment, multiple extractions and denture delivery. Their question was: How could we have extracted teeth that were not present when the denture was billed several weeks earlier by their restorative dentist and before their extraction appointment with me? My records were clean and indicated that these patients had their extractions and dentures delivered on the same day. Of course the patient brought their denture with them for delivery. The problem lied with their dentist who had billed the State for the denture at the time of the impression and not at delivery. A common practice by some dentists and one way a provider will be flagged and likely audited.https://www.facs.org/-/media/files/advocacy/bulletin-articles/2017_08_audit.ashx
https://southfloridahospitalnews.com/page/How_to_Avoid_or_Prevail_on_a_Medicare_Audit/693/1/
The Girldoc😉
Comments