RAC and ZPIC Audits: How to have a Successful Payer Audit?

In the last twelve months, there has been more money than ever before put into fighting fraud and abuse.  Contractors are requesting more charts than ever before to review for fraud and abuse.  How do you have a successful payer audit?  The simple answer is provide the documents requested, but there is more to it.

First, Make a checklist for each chart.  Pull each chart and copy all records requested.  The request period may not include the delivery or start date and copies of initial qualifying test results and/or chart notes, include them if it is pertinent to the determination of ongoing medical necessity for example rentals of equipment.  If you did not obtain the test results or physician chart notes at the time of the start of care, request them now because the physician is not penalized if he does not respond.  Physician failure to respond to a request is an error and results in “overpayment/error” paid by the provider.  It is in your best interest to gather and submit each patient record in an organized manner.  This needs to be top priority because you have limited time frame to produce and failure to respond timely results in overpayment calculations!

Have you seen or heard the “error rates” being published?  The way it sounds, ever provider will have an audit with an error rate, it is just a matter of time.  A error rate published March 1, 2010, by Noridian was over 102 files with 86% error rate.  This is a small sample to create a crisis over.

I would recommend you have an independent third party, whether consultant or your health care attorney,  review the records before you send them off.  You can typically be granted one extension.  Do not wait until the last minute to start this process.  If you have a large number, have someone review a sample then expand based on the determined error rate.

If more than 20-30 charts are requested, I would notify outside counsel.  I am receiving new clients weekly with 200, 300, 400 or more charts being requested.  To produce duplicate copies of these records and obtain physician records in 14-21 days may be difficult and still run your business.

If you haven’t received an audit to this point, be prepared for when it happens.  Any overpayment determination in a payer audit requires payment arrangements prior to the appeal process being completed.  Be proactive, have an audit of your business to be prepared for when that day comes.

Angela Miller of Medical Auditing Solutions LLC has been in health care compliance, billing, collections and HIPAA for over 18 years.  Ms. Miller has made it the  focus of the business to help providers run their businesses efficiently, collect money, and maintain compliance with federal and state regulations and coverage criteria.  Ms. Miller has extensive experience with Medicare and Payer audits.  Ms. Miller  also works as a contract compliance officer to provide an avenue to compliance training to staff, implementation of policies, as well as handling anything that affects cash flow from the initial intake to back end collections. You can visit our website at Medical Auditing Solutions LLC.


2 Responses

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  2. Great Post. Really it will help lot of people. Thanks for the post.

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