In addition to the OIG 2016 Work Plan to improve its audit programs, an additional $350 million was provided by the Affordable Care Act to ramp up the Health Care Fraud and Abuse Control Program anti-fraud efforts, which includes increasing scrutiny of claims before payment, investing in sophisticated data analytics, and employing additional law enforcement agents. It is important for physician practices to pay close attention to the new rules written into the healthcare reform law, which made the Medicare and Medicaid screening and enrollment processes tighter, imposed stricter federal sentencing for fraud offenses, increased stronger civil and monetary penalties for violations, created a new requirement for providers to return overpayments to CMS within 60 days, and required that providers establish a fraud and abuse compliance program.
Practices should ensure that they are in compliance with the federal regulations and understand all the statutes as they relate to fraud and abuse. One of the most important components for a successful compliance audit protocol is training and education. Once a problem is identified, it will be essential for the physician and staff to know how to respond or determine the best course of action. In this effort, the ACR’s practice management department has developed a comprehensive compliance and audit program to assist rheumatology practices in how to implement a self-audit program. The ACR’s certified healthcare auditors will train staff on:
- Auditing and monitoring claims;
- Developing compliance procedures;
- Understanding and applying documentation standards;
- Responding to audit reports/letters and creating appeals letters; and
- Developing corrective action plans for the practice.
Although it is normal for the word audit to incite some feelings of fear and anxiety, with a greater level of understanding of the audit process, the uneasy emotion can be diminished. The key to auditing is to evaluate processes and identify any areas of weakness. The most important step in the world of audits is for physician practices to be proactive. Efforts should be made to ensure staff are educated and up to date with all audit practices and procedures, including what areas are being targeted.
Understanding how to manage and respond to appeals, denials and audit request forms is crucial to keeping rheumatology practices running smoothly and profitably. The ACR can assist you with reaching that goal through training and education. Contact the ACR certified healthcare audit instructors Antanya Chung, CPC, CPC-I, CRHC, CCP, and Melesia Tillman, CPC, CRHC, CHA, to set up a course in your area. Call 404-633-3777 or visit Rheumatology for additional information.
