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How To Avoid A Medicare Audit



Medicare audits are assessments put in place to reduce improper payments to practices abusing the healthcare program.

There are several types of audits: Recovery Audit Contractor (RAC), Certified Error Rate Testing (CERT), and Probe. All of these use a Medicare Administrative Contractor (MAC) to ensure that different types of medical practices use the Medicare program lawfully.

While some Medicare audits are randomized, others can be due to suspicion. Even if your practice is currently running smoothly, it is important to continuously monitor procedures to ensure no fraudulent behavior goes undetected. Taking a cautious and thorough approach will help avoid the potential for a Medicare audit.

Understanding the Risks

As mentioned above, audits may be conducted if there are warning signs within a practice including the excessive use of the KX modifier, billing more than the average number of codes, and multiple physical therapists billing under a sole provider. Failure to be compliant with Medicare procedures can put your business at risk.

In the event of an MAC audit, practitioners should consult an attorney to understand their rights. However, practices themselves should also be in tune with these warning signs to address the issues before they turn into fraud.

How Can Fraud Occur?

Medicare fraud can be due to purposeful or accidental behavior that may not be noticeable without an audit. Common factors contributing to fraud include:

  1. Data: It is important that all physicians fully understand the data they or their technology are collecting. While it is easy to assume it is accurate, it is important to be knowledgeable about it in order to detect errors.
  2. Documentation: Document everything thoroughly and double-check its accuracy. It is also advisable to not copy and paste.
  3. Technology: Even the best systems can be prone to errors or security issues. Practitioners should be aware of how to work all software and periodically check that it is running properly.
  4. Employees: Whether intentional or not, human error can result in Medicare fraud. Practices should periodically check individual employees as well as continuously refer back to training. An easily accessible hand guide on procedures and codes may also be a good option to ensure everyone is on the same page.

Conduct Self Audits

Internal auditing can allow practitioners to spot wrongful behaviors and processes before the government, allowing them to self-correct their program and decrease punishments. Self-audits are beneficial in:

  • Reducing fraudulent payments
  • Encouraging compliance
  • Improving patient care
  • Reducing the odds of an MAC audit

The recommended process for an internal audit is at least 3 months of analyzing a random sample selection (5-10 records) of each professional in charge of billing Medicaid services, ensuring that each is reviewed by an unbiased, certified, and knowledgeable employee, and that none are self-reviewed.

Self Disclosure

If fraudulent practices are found in a self-audit, it is in the practice’s best interest to fill out a self-disclosure form to the U.S. Department of Health and Human Services Office of Inspector General, or to the state in which the practice resides. Forms can be sent online, by mail, or by fax.

Under False Claims laws, self-disclosing any fraudulent behavior found can lower the damage amounts and decrease potential exposure. If the self-audit finds improper claims for Federal health care dollars, the sum must be paid back within 60 days. Providers must then conduct a randomized sample of 100 claims in accordance.

Learning From Audits

An internal audit can raise practitioner awareness of faulty proceedings or even employees. If any fraud is found, it should be reported to the staff to ensure future compliance and growth.

Employees tasked with billing and coding should be properly trained and well prepared to minimize the risk of human error. Thus, it is always advisable to revisit training frequently even if there does not seem to be an evident problem to make sure all employees understand the tasks expected of them and feel comfortable with them.

Billing and coding errors that seem patterned or susceptible to future fraud should be carefully reviewed and adjusted accordingly. Findings from an internal audit can be used to correct current procedures in accordance with local and national coverage policies and prevent future mistakes.

Medicare Audit Attorney

Practitioners have the capability to combat Medicare fraud internally and reduce the risk that might come from failing an external audit. Thus, it is important to take cautionary action to avoid an MAC audit to keep your reputation intact.

The Medicare attorneys at Fenton Jurkowitz Law Group regularly defend healthcare providers in all stages of the audit and appeal process. Their dedicated and knowledgeable team can work with you to address individual concerns regarding documentation and procedures to minimize accidental fraud.

Contact us today to discuss concerns regarding Medicare/Medi-Cal audits, appeals, and overpayment disputes.