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incentives can sometimes become rather aggressive, using misleading recovery forays in an attempt to gain access to your medical records and provider
revenue. When you give auditors access to your claim data and medical
records, you do so with the assumption they'll assess proper use of service
codes, modifiers, comparative billing patterns, medical necessity supported
treatment, as well as documentation that properly supports all codes billed.
However, reports show a large percentage of appeal submittals are overturned as the result of unsupported audit findings.
Gone are the days of written notifications and corrective requests regarding
innocent billing mistakes and coding errors. Notifications involving reported
billing errors are becoming more unreasonable and perplexing. Don't be surprised if you receive irrational audit findings such as payment demands being
made based on discrepancies with documentation, even though the documentation meets appropriate guidelines and supports all codes billed.
Even with proper documentation and coding, an auditor may elect to use
another ambiguous reason to justify a determination that documentation is
insufficient and to warrant your refunding an insurance payment. It's not
uncommon for auditors to make determinations without adequate review of
all documents pertinent to proper claim adjudication. I've even witnessed
auditors reporting coding errors that support a claim that was actually
underpaid due to missed codes, then the provider was informed by the
payor to not bill a corrected claim unless the payor instructs them to do so.
These are just a few examples of practices witnessed by some auditors and
payors that choose not to acknowledge governing laws and certain rights
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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