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Are Your Auditors Broke Yet? If Not, Read On…

This was one factor in the OIG’s decision to partially restart the RACS, which merits discussion.

If audit responses efficiently managed, and charges are fully current, compliant, and documented, and then auditors won’t benefit from the costly administrative nightmare that many of the less scrupulous external auditors are causing when they perform, as the OIG puts it, “duplicative postpayment claims reviews.” Read more: http://www.gao.gov/assets/670/664880.pdf

CMS points out that these are,“.. reviews of the same claims that are not permitted by the agency—but CMS neither has reliable data nor provides sufficient oversight and guidance to measure and fully prevent duplication.”

What can a healthcare organization do about this?

The best defense is a good offense:

  • Get your documentation standards in place – always document the “risk” component and treatments.
  • Get your claims right the first time and then – if audited – appeal, appeal, appeal.
  • By performing your own internal audits, you can validate that your charges are fully current, complete and compliant. Don’t leave money on the table with missed charges through lack of internal oversight. You don’t want to risk getting it wrong, remember that noncompliance – even through error – is called fraud today.

Healthcare organizations’ internal auditors need to be more aware & competent that ever before.

No longer can healthcare organizations live on just Medicare. Today, awareness of Medicaid & Commercial payor plans is very necessary. Commercials are tough. The ever–changing rules from commercial payors make it very difficult. Plus, unlike Medicare, commercial payors don’t typically provide solid rules. This means healthcare organizations must piece the rules together themselves. And commercial payors generally have a poor way of communicating their rules to healthcare organizations’ auditors.

Tip to healthcare internal auditors: When reviewing claims make sure you review them from the perspective of the specific payor on the claim.  Always have your contract on hand when meeting with any external auditor auditing commercial claims – it can stop a lot of line-item denials before they start!

What are your experiences with meeting commercial payors’ requirements for reimbursable claims? What are some areas where you feel that your healthcare organization’s audit prevention initiatives can be improved? Think I missed something important? Let me know in the comments or tweet us @RIJourney with your ideas.