Medical Auditing

As a Practitioner you probably know someone who has been audited and fined some ridiculous sum of money. The best defense against a negative audit is in fact a good offense. PAS can help your Practice minimize your risk exposure by pre-auditing your practice billing algorithms or joining in the defense of your audit case.

There are many audit situations and a quick review will alert you to the severity of what you’re facing.

1. Your practice is probably being routinely audited on an ongoing basis by Medicare/Medicaid and private insurance companies. Mini-audits, or questions about 5-10 patients are frequently sent to your billing department. The completeness of the information they return is key to preventing the 10-20 patient review.
2. Private insurers who offer supplemental Medicare policies will sometimes try and audit 200-300 patient records. Their contracts with CMS often allow them to up charge the government depending on how many diagnosis the patient has reported to all the doctors from whom they are receiving services. These reinsurers are auditing your charts not to check up on you, but to find other information they can find out about the patient, and they want to do this at your time and expense.
3. Medicare or Medicaid audits are usually not discovered until a Federal Marshall or States Attorney or State Investigator show up at your office. These audits are usually triggered by either a patient or employee complaint. These investigators' knowledge of health care practices is frequently very limited and although they talk about all the major fraud they have uncovered elsewhere, they don’t understand your treatment protocols. Act respectful, call your malpractice carrier immediately, and call us! We would be happy to discuss what they looked at and where they may be incorrect in their assessments. We have worked on cases and inconsistencies that have led to the total dropping of the audit results.
4. RAC audits are gun for hire type auditors who are compensated for the gross "fraud" they uncover. As is the case with Medicare/Medicaid audits knowledge of your practice systems and policies is usually lacking and you are put on the defense by having to demonstrate that the care you give is from a billing perspective consistent with the best medical treatment for the patient.

Call PAS with any audit concerns or to set up a review and private audit of your billing so you can adjust your practices if needed to be appropriate and legal.