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1. Don't let language deceive you. It's not uncommon for auditors with a primary focus on recouping revenue to use "fraud and abuse" or "risk adjustment"
or another artistically defined excuse to conduct an audit and gain access to
your medical records and claim data.
2. Leave a paper trail. Third-party entities acting on behalf of payors do not
adjudicate or acknowledge appeal submittals. If you receive a payment
demand from a third party, submit the appeal directly to the payor's appeals
or grievance department, and send a copy of the appeal to the third party or
to the payor's recovery unit as proof you have properly responded to the payment demand.
3. Know your rights. How do you know if an audit request or audit findings
are valid? Knowledge is power. You and your earned revenue are protected by
certain rights and governing laws. You're in a much better position to level
the playing field and address deceptive practices if you know about protective rights and governing laws. You can legitimately respond to assertive auditor demands trying to force on-site reviews. A large percentage of claim
denials and refund requests fail to meet payor compliance requirements and
governing laws. Government Accountability Office reports for 2011 show that
39% to 59% of payor denials were reversed on appeal. The more your facility
exercises protected rights under governing law, the less likely it is to be victimized by disingenuous claim practices. OSM
Ms. Dittrich (medrevenue@bellsouth.net), a revenue recovery, denial management
and appeal specialist, is founder of MedRevenue Solutions in Atlanta, Ga.
O C T O B E R 2012 | O U T PAT I E N T S U R G E R Y M A G A Z I N E O N L I N E
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