Audits Are Here to Stay

Providers call me daily to ask whether audits have slowed down, and if they should be concerned about being audited. Actually, I am seeing more audits lately, whether CERT audits or audit letters from the DMERCs. And it's not just Medicare; a number of payers and insurers are auditing currently.

But if you are prepared, you will have nothing to worry about. Easier said, huh?

Your primary concern should be knowing what issues there may be with your files prior to being audited. Do not wait and just expect that all of your files are perfect. Too many times, I have walked into clients' offices and someone says, “You will probably not find anything; we just wanted you to look at our files to confirm they are all right.” When I hear that, I know it could turn out to be an exciting exit interview.

Have you looked at your files lately? Let's start by pulling 25 patient files at random. Review each one to make sure every file meets compliance with Medicare, state Medicaids and third-party insurers.

When you receive an audit notice in the mail, the auditor signing the letter will give you a deadline for sending the patient files they have requested. Always date stamp the letter you have received from the auditor, and call the auditor to ask for an extension if you do not have all of the physician progress notes requested in the audit. It takes time to obtain notes from physicians and copies from home health agencies, discharge planners, social workers, labs, etc.

Read the letter thoroughly, and give the auditor what he is asking for! Go down the checklist for each patient, and only mark off what you have or can obtain.

Most letters will ask for the following documentation:

• Signed, completed delivery tickets (verify they meet Medicare guidelines)

• Signed pick-up tickets

• Completed Assignment of Benefits

• Billing statements (coinsurance billings proving that you attempted to collect the 20 percent copay)

• Copies of CMN(s)

• Copies of Physician Orders and dispensing orders (if applicable)

• Correspondence to or from the beneficiary

• Photograph and/or detailed description of service

• Servicing/repair records

• Rent/purchase option letter

• Patient's date of birth

• Advance Beneficiary Notice (if applicable)

• Physician progress notes

• Any notes, lab results, x-rays, fitting documentation or correspondence from providers related to the treatment for this patient