Internal investigations of billing issues usually involve
audits. It is important to approach an audit carefully or the
auditors can create more risk for the organization by
misinterpreting the standards.
Thus, it is very important to know what you are auditing before
you audit. It seems simple but this is often overlooked. Fully
researching all the issues involved with a critical eye is key.
There may be subtle changes in coding, billing or coverage policy
or guidance that caused confusion. There actually may be little
reimbursement impact from the error.
After the regulatory scope and applicability are researched an
audit protocol should be drafted. The protocol should be carefully
worded and tied back to the research. There should be an
expectation that the government or opposing party is going to
obtain a copy at some point in the negotiation. If an attorney does
not draft the protocol, they should review it for language.
If there also is a government or payer review ongoing, review
the same records and make your own findings. If you are the one
doing the audit as part of a settlement or potential repayment, the
size of the audit sample and timeframe is very important. Usually
the best course is a smaller sample called a probe audit that
restricts or expands the audit as issues are found to have either
continued or have resolved.
Creating an audit report for negotiation is important.
Overpayments as well as underpayments should be included as offsets
are allowed and even specifically referenced in Medicare manuals.
The report should include a concise argument for the regulatory
position you are taking with regard to coding, contracting or
The content of this article is intended to provide a general
guide to the subject matter. Specialist advice should be sought
about your specific circumstances.
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