As concerns over the cost of health care rise, efforts to reduce those costs are similarly increasing. One of the most prevalent mechanisms used by third party payers to reduce health care costs is retrospective audits of those physician practices whose billing patterns differ from those of their peers, thus potentially suggesting fraud or abuse. Third-party payers and their subcontracted claims reviewers (many of whom stand to share in any monies they recover) hope such audits will uncover opportunities for significant overpayment recoveries, as well as create an "in terrorem" effect encouraging physicians to bill conservatively.
In this environment, audits are an inevitable part of operating a physician practice, but they can be managed. You may want to consult these AMA educational resources, developed in cooperation with the American Academy of Neurology, to learn useful tips and strategies that will protect your practice from the risks of an audit.
The best way to successfully navigate an external audit is by identifying possible trouble areas through conducting your own internal audits. This document will help you understand the value of an internal billing audit, as well as how to perform an internal billing audit to yield improved claims management processes, cash flow, and compliance with applicable laws and regulations.
Physicians and practice staff should refer to this document to learn about the recoupment efforts of health insurers through the retrospective audit process. You can use this resource to guide your practice through the whole retrospective audit process, from receiving a health insurer’s initial notification to contesting the audit’s findings.
Congress created the Recovery Audit Contractor (RAC) program to help the Centers for Medicare and Medicaid Services (CMS) identify improper payments made by Medicare. The RAC contractors are private entities that are retained by the government to identify overpayments or underpayments made to physicians and other healthcare providers, as well as, to recoup overpayments or return underpayments.
The AMA remains deeply opposed to the bounty hunter-like program.
- Private payer audits: What you need to know - Physician practices may be subject to as many as 20 different types of payer audits including federal, state and private payer reviews. "Private payer audits: What you need to know," the first webinar in our audit series, reviews the various types of private payer audits, how to minimize your risk of being audited, what to do if you are audited and what actions to take if the audit results in recovery dollars.
- Medicare and Medicaid audits: What physicians need to know - Learn how to navigate audits by Medicare and Medicaid. View, "Medicare and Medicaid audits: What physicians need to know," the second webinar in our audit series, which explains what every physician needs to know about the growing number of physician audits conducted under the Medicare and Medicaid programs. Hosted by a physician advocate and legislative attorney, this webinar covers the different types of auditors employed by the Centers for Medicare & Medicaid Services and describes best practices for physicians who have received a request from one of them. The webinar also includes a forecast of emerging physician audit issues. The slide deck to this webinar is also available.