How to Avoid CMS Audits

Center for Medicare and Medicaid Services (CMS) is an agency in the US Department of Health and Human Services. They work with the government to manage areas such as Medicare, State Children’s Health Insurance Program, Medicaid, and the health insurance portability standards. They work to ensure things like laboratory quality standards, long term care facility quality, and work against abuse, fraud, theft, and waste of money that could have been spent on the health of the Medicaid recipients.

Auditing is the inspection of a company’s finances and accounts mostly by an external source. It makes sure that the company is maintaining its book of accounts as stated by the law. CMS audits are an integral part of billing, and even the thought of having a hospital or your practice audited is unpleasant. The rules are ever changing and there is a possibility that one makes a coding error or does not initiate the usage of ICD-10. This makes them fall behind, as their system, infrastructure, and technology starts to lack as soon as there is an update. If an organization is not up to date with the changes, it can lead to financial problems and there might be a need to pay back funds that are not allowed.

President Obama’s Executive Order # 13520, “Reducing Improper Payments and Eliminating Waste in Federal Programs”, is the reason why many hospitals and physicians get audit letters so that there is fraud, waste, and payment errors. Centers for Medicare and Medicaid may be demanded a repayment of claims if any of the following happens:

Audits have become extremely important for all healthcare organizations since Medicare Audits started happening nationwide. Remember that a Recovery Auditor Contractor (RAC) has the authority to view your non-payments without even asking for your medical records. It is a good idea to follow these points:

1.   Be Prepared

Firms need to be prepared and should not be caught off guard in case of an audit. Stay ahead of a potential audit and make sure that whatever the results are, they are favorable in nature. Also, be aware of overpayments before a RAC learns about it and sends you a notice. In order to learn how internal audits work, go through the work plan of the Department of Health and Human Services (HHS) and RACs website on the internet.

2.   Be Prepared For the Worst

If you are prepared for the worst, no audit can catch you off guard. Keep your documents prepared, and know which documents you have to keep, and how your system should be working. Most importantly, know what information the employees must know of in order to be compliant. If these practices are done frequently, it may as well be a ‘pre-audit’ that will make the workers well aware of the entire procedure. This way, when the actual audit is done, the firm is prepared and remains unharmed. Furthermore, because of a pre-audit, you learn where you are making mistakes such as duplicate services billed etc. Also, make sure that you thoroughly look at your billing data because RACs scrutinize them with the help of their software.

3.   Hire a Medical Billing Company

In order to ensure that there are no discrepancies and errors in billing, and that billing work is done efficiently and on time, hire a medical billing company. They can and help you with the error free ICD-10 coding that is based on CMS guidelines.

4.   Be Punctual

Be punctual with presenting your medical records if an RAC asks for them because if you fail to do this, you will automatically be thought of as someone who has billing problems, and this can lead to a demand letter. It is a fact that several RACs have collected a lot of money from organizations being audited who failed to respond on time. If it is not clear what type of audit it is, then the concerned authority should be contacted to learn more about the nature of the audit.

5.   Avoid Any Variations

Auditors usually look for disparities in the information that is supported and what should have been done. If one knows of all these procedures, and removes the errors and mistakes, then discrepancies can be reduced to a certain extent.

6.   Document Everything Important

Sometimes, several systems are involved in an audit so organizations must make sure that details are documented to overcome any doubt. This includes the information that is present in reports generated by the EHR and all other evidences. It is necessary for researching and to give reasons for your actions that have been done after or during an audit. It is much easier for companies that have proper documentation of every decision and move to detect troublesome areas and to address the processes that are identified in an audit.

7.   Have a Qualified Team

This is perhaps the most important tip that we can give you. Most of the times, healthcare organizations fail audits due to human error. If you have a well trained and experienced team in the billing department, it will be thought of as an important driving force of revenue for your organization. Professional billers and coders who are certified by authorized associations make less mistakes as they know how organizations work, what the problems are, and how to come up with solutions which can bring higher revenues over the long term. If you want to be extremely safe, hire an audit firm to do the audit for you. This is extremely necessary if you want to avoid any serious actions against you by the RAC such as penalties or fines. A third party audit knows what RACs look in to, so they especially address those problems.

References

• http://ezinearticles.com/?Medicaid—The-Centers-for-Medicare-and-Medicaid-Services&id=5067559 

• https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index.html?redirect=/medicaidintegrityprogram/ 

• http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/Report-To-Congress-Recovery-Auditing-in-Medicare-and-Medicaid-for-Fiscal-Year-2012_013114.pdf 

• http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=72