Surviving an Audit

I’m often asked about how to avoid a Medicare audit. There is only one response I can think of, and that is to quit billing Medicare. Since that’s not a reasonable response, I suggest instead that you take the time to prepare for the inevitable audit. Whether it’s a widespread prepayment review or a provider-focused post-payment review, suppliers must take steps to ensure that they respond quickly and accurately. Your only defense in an audit is documentation, so for the purposes of this article we will focus on that very important element.

Insufficient Documentation

The biggest problem concerning audits, without question, is physician documentation being deemed insufficient. Recent changes to the Medicare Program Integrity Manual, which guides audit contractors, have reflected what we are noticing in these audits. The Centers for Medicare & Medicaid Services (CMS) wants to see that the physician documentation specifically addresses the criteria listed in the Indications and Limitations of Coverage section of the Local Coverage Determinations, and that it is documented in their notes as well as in the normal format that they document their own services. This seems reasonable, in theory, except for the fact that CMS does not fund the DME MACs to educate physicians and the Part B MACs are not funded to educate physicians on DME policies. So physicians do not know what they are supposed to document—it’s up to you to educate them.

While it may not be feasible to request documentation up front in all instances, CMS and its contractors seem to believe it is. I’m not sure what to do to resolve that issue, but what I can recommend are some ways to encourage cooperation from physicians by touting the term “compliance.” It’s not an option for physicians to comply, it’s the law. Unfortunately, CMS has put the responsibility on you to educate the physicians, and there has been little—if any—liability placed on physicians who do not comply.

Recently, however, we have seen an increase in additional documentation requests (ADRs) because contractors are auditing the physicians, so perhaps they will be more aware and willing to cooperate. We must come together and hold physicians accountable, so begin educating your physicians of their legal obligation. It’s not your requirement that you provide documentation, it’s Medicare’s requirement, and in order for you to be in compliance with federal regulations you need the documentation. As a result, the physicians may become the target of an audit because their documentation is not being deemed sufficient, so why not work with a company that is taking the extra effort to be compliant? It’s a great marketing tool in an environment of intense regulatory oversight that is now affecting other health-care providers, including physicians.

Patient Accountability

Another important topic to address is holding your patients more accountable. If you get the patients involved in their treatment and care, and educate them under what circumstances Medicare will cover the equipment that was ordered for them, it helps them understand what is needed to get their claim reimbursed accordingly so they are not liable. If you explain to patients that their physician has failed to comply with the request for documentation, and as a result they may be responsible for payment of the services, they will naturally be motivated to contact their physician.

While most physicians may not be concerned over your claims getting paid, they would likely be concerned if the patients call to complain. A successful practice must keep their patients content. While I advocate for the use of Advance Beneficiary Notices (ABNs), I also think it is extremely important that you fully explain the document to the patients so they understand what they are signing. The form should be specific and unique to that patient’s situation. It’s a fine line the provider must walk between alienating referral sources and patients, but both of these groups must take an active role in the care you provide.