Tips to Surviving Medicare Audits

Nobody wants to hear the word “audit” but unfortunately they are a necessary evil. Medicare uses audits both internal and external to reduce or eliminate fraud and waste. Sometimes they are looking to catch the providers who are purposefully defrauding the system, but sometimes they are looking for the providers who do not realize they are doing anything wrong. In any case, it is crucial that you are doing everything possible to make sure you (your office) are following the guidelines. The best way to do that is to understand what they are looking at and why.

One of the things that CMS is looking for is billing above the average for your specialty and patient load. They have national averages for providers and if a provider bills for E&M services and they continuously bill for the higher E&M codes without billing for any of the lower E&M codes, CMS is interested in why. For example, if a provider always bills using 99214 or 99215 and doesn’t bill any 99211, 99212 or 99213’s, this may trigger an audit. Now it may be perfectly legitimate and the provider truly meets the criteria for the higher codes, but their documentation must support that. On a national platform, the average provider billing E&M codes bills a variety, and not just the higher codes.

Another example would be a chiropractor who only bills using one of the manipulation codes. There are different manipulation codes that depend on the number of regions of the spine that are manipulated. 98940 is for 1-2 regions, 98941 is for 3-4 regions, etc. We knew a provider who just billed 98941 for any Medicare patient. Because he used the one code, it triggered an audit. After Medicare reviewed his charts, they determined that based on his documentation many of the visits should have been coded as 98940’s which is a lower reimbursement. The provider had to reimburse Medicare for the difference.

Bottom line, it is important to code exactly for the services performed, and to document the patients’ charts to support the services.

Another thing that CMS looks for is that services were medically necessary. Again, assuming you (the provider) is not ordering services or performing services that are not medically necessary this isn’t a problem. Make sure that when services are provided or ordered that all supportive information is well documented in the patient’s chart.

If Medicare informs you that they will be auditing your office, the best thing to do is to cooperate fully. When they notify you, they usually specify when they will be conducting the audit and what they will need. If you do not understand anything, give them a call and ask for explanation.

CMS and their contractors regularly educate and provide outreach to providers. They have much information available on their websites, as well as list serves (email updates) and audio conferences. Some of the contractors offer seminars throughout their area as well. Basically they are trying to help providers understand what is needed and how to accomplish it. Many times, they will give a provider an opportunity to right the mistakes as long as the offenses are not big ones. It is important that each office understand the guidelines and do all possible to make sure the office is following them.

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4 Responses to “Tips to Surviving Medicare Audits”

  1. Veeresh Says:

    nice post.. helpful….

  2. Barbara Griswold, MFT, author, Navigating the Insurance Maze: The Therapist's Complete Guide to Working With Insurance -- And Whether You Should Says:

    One of the things I liked about this article is that it didn’t make the insurance plan sound like an evil enemy out to get you. My understanding is that besides trying to catch those committing fraud, and looking for providers who are not aware they are doing things wrong, with all insurance plans a certain number of random audits are required by the organizations that credential insurance plans for quality assurance, so you may be chosen randomly. You may also be targeted if a client complains about you to the plan.

  3. sue Says:

    Question: My provider is getting rejections because he doesn’t have a referral from PCP. How does he know the patient needs one? Sue

  4. solutionsmedicalbilling Says:

    What is his specialty again? Medicare requires referring provider info on certain services. I have some providers who actually are the provider who rendered services and the referring provider. For example, I have a dr who does an EKG in the office. The EKG requires referring provider info but he is the one who determined it was needed, and did it himself. He has a private practice now, but was an ER dr for 20 yrs. On Medicare claims for the EKG he is both the rendering & referring provider.


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