Audits by private carriers tend to be easier and quicker to resolve
than CMS audits, which feel like a bureaucratic nightmare. It's
extremely difficult to talk to a live person and your appeals can spend
years in backlogs. In 2017, the Secretary of Health and Human Services
identified more than 600,000 appeals handled by fewer than 2,000
judges leading to a backlog that could cause a delay of 3 to 6 years
from the date of appeal to the date of the hearing in front of the judge.
There's now a process in place to settle CMS claims before the matter
is heard by an administrative law judge. A recent case law precludes
CMS from recoupment while the appeal is pending
(osmag.net/MZAn9k).
Prevent defense: self-audits
How can you avoid an audit? The plain truth is that you should be
preparing for a possible audit well in advance of receiving one of
those letters.
Your best defense? Regularly perform your own billing audits, either
internally, or by using a trusted third-party provider, so that you can
avoid getting audited in the first place.
It's easy to get wrapped up in the day-to-day of operating a facility.
Bad practices and habits tend to gather momentum and snowball over
time. What might have started as a shortcut or an oversight in 1 or 2
cases can become an epidemic within your center, and the fact that
the bills are being paid could easily lead to a false sense of security. A
self-audit can be a chore, but it is the most reliable way to avoid an
external audit.
Beyond that, keep close track of medical coding changes, particular-
ly in evaluation and management (E/M) coding — not just to avoid an
audit, but also for the more practical reason that some of your mis-
coded claims might be denied or ignored.
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