What Can Trigger a CMS Audit?

No medical office looks forward to an audit by the Centers of Medicare & Medicaid Services (CMS). Even practitioners who are supremely confident in both their compliance and the quality of their record keeping are still likely to cringe at the amount of work an audit can entail. Much like a tax audit by the IRS, a medical practice cannot avoid being selected for a review by CMS. However, also much like a tax audit, certain things tend to make contact with CMS much more likely. Knowing these things and adjusting practices accordingly can help health care providers avoid auditing or at least be better prepared when an audit does occur.

CMS utilizes both front-end and back-end review processes to identify and correct mistaken or fraudulent claims:

  • National Correct Coding Initiative (NCCI) — The NCCI reviews initial claims to identify improper billing code combinations prior to payment of claims.
  • Medically Unlikely Edits (MUEs) — MUEs identify instances where an inappropriately large number of units for a given service are billed on behalf of a single beneficiary and makes corrections prior to payment.
  • Medical Review — This in-depth review of supporting medical records is usually targeted against providers for whom other review processes have revealed exceptionally high error rates. A Medical Review may be conducted either before or after payment.
  • Comprehensive Error Rate Testing (CERT) — The CERT process selects random individual claims to be reviewed for proper medical documentation, medical necessity and correct coding. Providers found to be out of compliance after a CERT audit may be subject to Medical Review on future claims.
  • Recovery Audit Program — This program targets previously processed claims not yet reviewed under any other process. Once a claim is identified as likely to be erroneous, auditors conduct an in-depth review using the patient’s medical records.

A New Jersey Medicare compliance attorney can provide medical practitioners with support during the audit process and can also help doctors take advantage of their appeal rights.

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Posted in: Healthcare Criminal Defense, Regulation