Cath Lab Digest

While undergoing a Medicare audit can be a stressful situation, this author emphasizes cooperation and documentation, and outlines key factors that commonly trigger an audit of one’s practice.

     You have been notified that you are about to be audited by Medicare. Do not panic. Audits are simply the cost of doing business. Many entities may audit you during the lifetime of your practice. Your practice may be subject to audits from insurance companies, health maintenance organizations (HMOs) and even the Internal Revenue Service (IRS).

     When you receive the initial letter, read it carefully to determine exactly what information they want. Send in chart notes for the specific dates of service requested as well as any other documentation that would support the services rendered on that day. This could include laboratory results, X-ray reports, photographs, consultations from other physicians, etc.

     When reviewing the audit letter, especially if the letter requests multiple charts, see if there seems to be some type of underlying theme in the chart notes. Were the requested patient charts those of nursing home patients, surgical patients or routine foot care patients?

     It is very important not to alter the record in any way. If you do remember additional information, create an addendum that you should clearly mark as an addendum. Sign and date the new entry.

     When sending the records, make sure you specify “return receipt requested” so there is no confusion as to whether the auditing body received the records in a timely fashion or at all. If you do not reply to the audit notification, Medicare or other auditing agencies may impose fines/penalties or deduct money from future payments.

     When you are corresponding with these individuals, ask what their timeframe is to get a response. Often if the response is favorable to you, you may not hear back from them at all. At least you have an idea of the timeframe.

     When corresponding with the auditing agency, please try to be polite even though this is a stressful situation. Be professional in the discussions or correspondence with these people. Ranting and raving will not help the situation at all. These people are trying to do their job as well.

     If you find that the review of your records during the audit process is unfavorable to you, there is an appeal process, which should be outlined. Read this appeal process carefully. Generally, there will be a timeframe mentioned. You must respond within this timeframe or you may lose your appeal rights. If additional information is requested or becomes available, send it in as well.

A Guide To The Various Kinds Of Audits

     There are several types of audits that you might be subject to: CERT, RAC or a formal audit.

     The Carrier Error Rate Test (CERT) audit is a single chart audit, which may date back two to three years. This is more of an audit of the Medicare carrier than of the physician. However, you will be asked to refund any overpayment. This is a way to check to see if the carrier processed the claim correctly. The auditor may select certain CPT codes for review. If the claim was processed incorrectly, generally any monies that one will ask to be refunded will pertain to that one single claim. A broad scale audit does not evolve from this type of audit.