Audits Are Here to Stay

Providers call me daily to ask whether audits have slowed down, and if they should be concerned about being audited. Actually, I am seeing more audits lately, whether CERT audits or audit letters from the DMERCs. And it’s not just Medicare; a number of payers and insurers are auditing currently.

But if you are prepared, you will have nothing to worry about. Easier said, huh?

Your primary concern should be knowing what issues there may be with your files prior to being audited. Do not wait and just expect that all of your files are perfect. Too many times, I have walked into clients’ offices and someone says, “You will probably not find anything; we just wanted you to look at our files to confirm they are all right.” When I hear that, I know it could turn out to be an exciting exit interview.

Have you looked at your files lately? Let’s start by pulling 25 patient files at random. Review each one to make sure every file meets compliance with Medicare, state Medicaids and third-party insurers.

When you receive an audit notice in the mail, the auditor signing the letter will give you a deadline for sending the patient files they have requested. Always date stamp the letter you have received from the auditor, and call the auditor to ask for an extension if you do not have all of the physician progress notes requested in the audit. It takes time to obtain notes from physicians and copies from home health agencies, discharge planners, social workers, labs, etc.

Read the letter thoroughly, and give the auditor what he is asking for! Go down the checklist for each patient, and only mark off what you have or can obtain.

Most letters will ask for the following documentation:

• Signed, completed delivery tickets (verify they meet Medicare guidelines)
• Signed pick-up tickets
• Completed Assignment of Benefits
• Billing statements (coinsurance billings proving that you attempted to collect the 20 percent copay)
• Copies of CMN(s)
• Copies of Physician Orders and dispensing orders (if applicable)
• Correspondence to or from the beneficiary
• Photograph and/or detailed description of service
• Servicing/repair records
• Rent/purchase option letter
• Patient’s date of birth
• Advance Beneficiary Notice (if applicable)
• Physician progress notes
• Any notes, lab results, x-rays, fitting documentation or correspondence from providers related to the treatment for this patient

If the DMERC receives this information but it does not prove the equipment to be medically necessary, Medicare will request a full refund for what they paid you on this patient. And a global analysis could possibly make your overpayment as much as three times the original fee or more.

I strongly suggest hiring a professional consultant and/or health care attorney to review and assist with audit requests. There have been substantial overpayments collected from providers by all four DMERC regions due to poor documentation. But remember, even when you hire a consultant or attorney, they are only assisting you with the audit you have received — and their advice will only be as good as the information they receive from you.

Make it a practice to obtain the appropriate documentation at the time of intake to ensure you can pass an audit when your name is selected. If you have already received an overpayment letter, an attorney or consultant can assist you here as well, but once again, they will only be as effective as the documentation you are able to obtain. The letter for the hearing will come back to you, and you must make sure you have sufficient documentation to fight the audit.

Audits are here to stay. Be prepared, and make sure your staff is prepared if it is not a mail-in audit and an auditor walks in your door instead. Be polite, friendly and cooperate so the auditor can obtain the information he has been hired to get.

Being prepared may save you a lot of money in the end.

Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at [email protected].