Compliance Auditing: Monitoring Business Practices to Reduce Risk
In an effort to control costs, the Federal Government has increased examination of Medicare reimbursement. Providers in all specialties are seeing greater scrutiny of billing practices and coding, with a particular focus on the use of observation codes, evaluation and management (E&M) codes, and pain management codes.
Medicare recently introduced a nationwide Recovery Audit Contractor (RAC) program under which private contractors are given contingency fees for identifying improper Medicare reimbursements - including under- and over-payments.
These contractors use data mining, outlier analysis, and referral rules to identify improper payments. If a RAC audit finds a payment error, the contractor can apply that same error rate across all Medicare patients over multiple years and substantially increase any penalties.
In addition to potential RAC audits, providers and hospitals must also prepare for Carrier Error Rate Testing (CERT) audits by performing internal outlier analyses to understand how their documentation, coding, and billing compares with others in the geographic area.
During a Compliance Audit, our team will analyze how your providers are documenting charts and how those charts are being coded. Our coding professionals have completed peer reviews and conducted internal control audits for various healthcare specialties and they have the experience and certifications to audit both professional and facility codes.
In addition, MRI's vast proprietary database of coding and charge information enables our team to analyze your documentation and billing activities against the norms for any specialty within a geographic area to identify areas for improvement and potential risk. As a result, your practice will be ready to respond to and defend your activities in the case of an audit or inquiry.