CMS points out many audits being performed are duplicative, “… 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.” Source: http://www.gao.gov/assets/670/664880.pdf
So, duplicative audits can only be identified by hospital organizations that can identify when an audit has previously been performed on the same claim. Those without such defenses must respond to the same audits over and over again, spending costly operational resources to keep up.
If you are having a feeling of déjà vu…don’t worry…it’s not just you! In fact, only 21 percent of execs felt they were in a strong position for appealing RAC and other audits in a recent survey sample.
Can you imagine if other servants of the public’s well-being had to repeatedly bill and defend their weekly wages from multiple computer databases without consistent oversight?
In response to concerns, CMS has implemented a database to track recovery auditor (RA) activities.
As the diverse types of audits extend across an expanding range of commercial payor plans, and as these audits ramp up to the maximum allowable limits on each type of audit, it is vital to be prepared.
Do you know what your organization is doing while, CMS takes actions to improve its coordination across the range of its audit contractors? Being efficient in managing these audits is vital as deficiencies in this area can cost you in terms of reimbursement and compliance penalties.
Key takeaways for health system leaders:
- Be aware that duplicative audits are happening,
- Work to identify when and where these duplications exist, and
- Shore up your defense and offense to manage audits.
The central control point for identifying opportunities to improve your position is in your chargemaster (CDM). The CDM holds keys for both offense in preventing audits and efficiently obtaining reimbursement and defense against audits.
Keys to your offense in preventing audits and obtaining reimbursement are:
- Ensure correct coding,
- Be current with ongoing changes to compliance regulations and rules,
- Understand modifier do’s and don’ts in the CDM, and have multiple eyes with necessary expertise and current reference materials review data in the CDM.
Keys to your defense include close review of RAC edits and RAC Team findings, and comparing your audit history records with your CDM data – preferably using automation as recovery auditors use tools.
Have you seen duplicative audits coming simultaneously from diverse audit contractors? Your ideas about identifying duplicates and your experiences in communicating about duplicates are of interest.