Medicare Audit Defense

Medicare Audit Defense2018-10-24T19:14:58+00:00

If you treat Medicare patients, audits and survey are likely unavoidable. Centers for Medicare & Medicaid (CMS) policies are continually changing, so it’s important to stay updated to remain in compliance. Below, we discuss common issues that can trigger an audit, what an audit may reveal, and the importance of finding a local Medicare audit defense attorney.

Common Audit Triggers

CMS use data and statistics to recognize over and under-coding incidents. If your practice falls outside of the norm, you are more likely to receive an audit. Excessive modifiers can also increase your risk.

Electronic Health Records systems make it tempting to copy and paste, but that often creates cloned documentation. Use templates for documentation, but if each note doesn’t have data that supports medical necessity, it could be a red flag.

Patient complaints and disgruntled employees can also increase your audit risk. Provide employees with a way to report dissatisfaction and talk to unhappy patients if they believe they didn’t receive the correct treatment or services.

billing errors - Medicare Audit DefenseBilling Errors

Other problems may involve billing. Errors include billing for services a patient didn’t receive or for care provided by a student. If a technician or aide provides services, it should be reflected in patient records and billing. CMS also frequently uncovers incidents where providers intentionally submitted claims for services Medicare doesn’t usually cover and claimed they were necessary but didn’t provide evidence. Medicare deems payments improper when they are for an incorrect sum or are requested by a provider who isn’t eligible.

Issues Uncovered

Insufficient or incorrect documentation causes most of the problems auditors uncover. When CMS conducts an audit, these are the most common coding errors:

  • Records don’t contain readable signatures and credentials.
  • Electronic health records aren’t electronically signed.
  • ICD-9-CM codes are not precise with the highest degree of specificity.
  • The diagnosis code on the bill doesn’t match what the provider wrote on the patient’s record.
  • Cancer status and treatment are not documented.
  • Records don’t contain a yearly status code and documentation for chronic conditions.
  • Documents were modified after denial.

Other problems may involve billing. Errors include billing for services a patient didn’t receive or for care provided by a student. If a technician or aide provides services, it should be reflected in patient records and billing. CMS also frequently uncovers incidents where providers intentionally submitted claims for services Medicare doesn’t usually cover and claimed they were necessary but didn’t provide evidence. Medicare deems payments improper when they are for an incorrect sum or are requested by a provider who isn’t eligible.

When to Call a Lawyer

If you have received a letter from a Medicare contractor requesting records, this could indicate you might be facing an audit. Medicare audit defense attorneys will have experience representing providers and dealing with Medicare guidelines. They also often have relationships with documentation experts who can answer your questions and help you evaluate the audit process.

Once you’ve found Medicare audit defense attorney, he or she can help you respond to the contractor in a timely manner. The type of audit you face determines its focus and scope. A knowledgeable healthcare attorney can walk with you through the process and help you understand potential penalties and the appeals process.