RISKY BUSINESS ?
RISKY BUSINESS ?
in compliance with coverage , coding , payment and billing practices .
PRE-PAYMENT AUDITS
After conducting a probe audit of a provider ’ s Medicare claims , a MAC or ZPIC may place a provider on “ Pre- Payment Audit ,” also referred to as “ Pre- Payment Review .” Prior to beginning provider-specific review , MACs and ZPICs should notify providers through written communication . RACs conduct pre-payment reviews under the “ RAC Pre-Payment Review Demonstration ” on certain types of claims that historically result in high rates of improper payment .
POST-PAYMENT AUDITS — POST-PAYMENT
Audits are conducted after the Medicare claims have already been paid by the government . Contractors strictly apply coverage requirements and therefore it is not unusual for them to find that a provider failed to comply with each and
" IT IS CRITICAL TO KEEP ABREAST OF THE MOST RECENT DOCUMENTATION REQUIREMENTS AND BE VIGILANT IN COMPLETING THE STEPS TO OBTAIN THE PAPERWORK TO REMAIN COMPLIANT ." every requirement . Depending on the nature of the initial sample , a Contractor may extrapolate the damages in a case , which significantly increases the alleged overpayment . Contractors extrapolate the damages to effectively claim that the “ sample ” of claims audited are representative of all the claims submitted by that supplier .
There are many factors that can trigger these audits . Most organizations that receive audits on a reoccurring basis are more than likely being targeted for noncompliance or because of previous issues . Some organizations are audited at random based on data analysis and billing patterns . Many providers don ' t realize that there are steps they can take to try and prevent being targeted . It is critical to keep abreast of the most recent documentation requirements and be vigilant in completing the steps to obtain the paperwork to remain compliant . If your office and staff are prepared for the worst at all times , an audit won ’ t paralyze you if and when you should receive one .
Some processes you should enforce and be sure that your staff follows at all times are listed here . Be sure that your entire staff stays up to date on policies , procedures and regulations as well . Keeping them educated on the LCD & NCD documentation requirements is critical if they are in charge of your patient files .
O Review every process your staff follows daily
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