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Part B News Quotes John W. Leardi on Navigating a Medicare Advantage Organization (MAO) Audit

John W. Leardi was quoted throughout the Part B News article “MAOs More Motivated to Audit; 4 Tips Will Help Your In-Person Process,” about the new standards for audits of Medicare Advantage organizations (MAO) and what practices should do to cooperate with the new regulations while also ensuring that their rights are protected. 

The article stated that the primary purpose of MOA audits has traditionally been to assure the Center for Medicare & Medicaid Services (CMS) that claims the MAO submits to them are billed and coded accurately. 

Leardi said that the “unique situation” of Medicare Advantage is that MAOs are reporting diagnosis codes they receive in claims from providers and they are not receiving the underlying medical records every time a claim is submitted. 

“So essentially they’re taking the provider’s word for it,” Leardi said. “And when Medicare wants to then audit those diagnosis codes, the medical records are the source material they want, and the only way to get the underlying medical records is [for MAOs] to go to the provider.” 

Leardi added that with the new regulatory motivation, MAOs may want more from their audits than just to satisfy CMS’ curiosity. His advice for practices when faced with a MOA is to engage with the MAO and its auditors on a common-sense basis.

“You don’t want an auditor showing up unannounced and demanding records while you’re in the middle of a busy waiting room.”

Leardi also advised having a lawyer in the room who understands medical coding and documentation.

“The idea is not to be an obstacle or to make things difficult,” Leardi said. “But one thing that happens when someone is interviewing mid- or low-level employees in an organization is, sometimes information is inartfully provided — there are mistakes and misunderstandings, and something as simple as not following up on a poorly worded question can lead to suspicion or even an improper allegation being made against the provider.” 

The full article can be read at Part B News (subscription required). 

  • Posted on: Jan 23 2024