The word audit seems to put fear into the hearts of many physician practices across the country—and it shouldn’t. If you are prepared for an audit, your practice will run more smoothly from both a financial and personnel standpoint.
The Recovery Auditor Contractor (RAC) program was made permanent by Congress to help the Centers for Medicare and Medicaid Services (CMS) identify overpayments and underpayments. The amount of money recouped by RACs and the number of claims reviewed should make it worthwhile for you to review the ins and outs of the audit process and what to do in the event an auditor knocks on the door.
Due to the new appeals process and guidelines, you should consider the necessary resources and training that staff will need to appropriately respond to audits, as well as to appeal an unfavorable audit. The key to dealing with an audit is responding immediately to any correspondence that is received; even more important is appealing an adverse audit. There is a very high success rate in winning a decision of an RAC audit through the appeals process. In a June 2010 CMS program update, it was revealed that, “When providers choose to appeal a RAC determination, providers win 64.4% of the time.”
As soon as a “demand letter” is sent, the clock starts ticking, so disputing the RAC findings of an overpayment should be done quickly. To appropriately appeal audits, it is vital to know and understand coding and documentation guidelines. Review this month’s Practice Pearl on page 20 for a step-by-step appeals process. Review all polices and regulations to stay abreast of changes and updates. Keep in mind that the RAC must follow Medicare policies, national and local determinations, regulations, and manual instructions when performing a claims review. Additionally, minimize audit risks by performing self-audits quarterly or twice a year because the recovery audit contractors usually find issues with documentation.
Remember, receiving an audit letter is nothing to fear as long as you are familiar with the audit process and understand coding and documentation guidelines.
Visit the ACR website at www.rheumatology.org/practice to locate the necessary guidelines on key documentation and coding. For additional questions or information on coding and audit presentations in your area, contact Melesia Tillman, CPC, CRHC, CHA, coding specialist for the ACR at mtillman@rheumatology.org or (404) 633-3777, ext. 820.
Melesia Tillman is the coding specialist for the ACR.