Avoiding scrutiny under the new CMS audit process

September 5, 2017

With CMS recently announcing the agency is directing its Medicare Administrative Contractors to focus their audits and claim reviews on providers with consistently high error rates, it’s important to understand specifically what shortcomings could put your claims process under the microscope.

CMS has said the goal of this new initiative, dubbed the Targeted Probe and Educate Pilot, is to prevent fraud, avoid unnecessary payments and to be less of a burden on providers whose billing operations are running smoothly. Select MACs will be asked to choose claims for services that carry a significant financial burden for Medicare, in addition to those that produce consistently high error rates.

The good news is that unlike the old review system, which included all providers for a designated service during the initial round, providers who are already submitting claims with low error rates will be exempted from the review process.

Unfortunately, while this new process will reward compliant health systems with less oversight, those who are found to be consistently falling short of CMS’s standard will need to show substantial improvement between reviews to avoid penalties. Those who are determined to still have an undesirable error rate after three rounds of review could face actions such as referral to a recovery auditor or 100 percent pre-pay review. Providers must display an ability to reduce their claims error rate between rounds of review in order to be removed from the cycle.

So what does this mean for the average group? For starters, it’s more important to ensure your billing staff is informed of this change and is working with you to minimize coding errors.

Even small mistakes could put you under the crosshairs of the new process. In one recent example, our audit team reviewed a caseload where  we found 2 percent of cases reviewed had a coding error that caused prostate TURP to be billed as G0416 to Medicare after the biller’s system mistakenly updated 88305 to G0416! Repeated mistakes like these are what MACs will be looking to identify.

If you have any concerns about your claims process, now may be the time to consider preemptively bringing in a third-party auditor to review your work before the government comes calling. Vachette has worked with hundreds of clients throughout the nation and has the ability and expertise to identify and correct problem areas in your billing operation.

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