The Auditors are Coming, The Auditors are Coming!!! from Brad Rethwill Dc, Eugene

[Guest guest]

HNA

Welcome to our PhysicianTrends Blog. We're here to talk about physicians and how they are changing in the midst of the most massive transformation in our healthcare system since Medicare.

« Another Surprise for Small Businesses Courtesy of the Healthcare Reform Bill

The Auditors are Coming, The Auditors are Coming!!! (September 10, 2010)

Are you ready for the increased scrutiny that is (actually, already has been) coming to try to reduce the payments to providers and hospitals under the laws that require Medicare to be budget neutral. (Why Medicare is singled out to actually adhere to budget neutrality is another topic altogether). In order to achieve budget neutrality Medicare will increase premiums, raise deductibles, and increase recovery of ‘over payment’ to providers. In today’s political climate, with the economy struggling, and liberals running full speed toward socialism, who do you think will bear the brunt of these changes in paying for Medicare? The poor, elderly Medicare recipient, or the rich, greedy Provider?

From 2005 to 2008, the Center for Medicare and Medicaid Services (CMS) conducted a 3 year pilot program in New York, Florida, and California. The CMS hired an Recovery Audit Contractor to review providers’ claim submissions for accuracy and medical necessity. The result of this demonstration project was that, AFTER expenses, the CMS was able to save $3.73 for every dollar it spent to perform the audit. That’s a pretty good return on any investment. The CMS was so encouraged by the results of this demonstration program that it will have implemented a similar program in all 50 states by the end of 2010. Don’t think that private insurance companies are not aware of this program, and have or will be implementing their own audits of claims submitted by providers.

The auditors will be focusing on any discrepancy between the billing and the SOAP notes. First, they will be looking to see if your notes correspond with the dates and types of services for which you billed. Then they will scrutinize your notes to make sure that they comply with all State and Federal regulations and demonstrate ‘medical necessity’. If the auditors find any discrepancy between the billing and substantiation provided by the notes, the provider will be directed to return the money already paid to them.

The bureaucrats have done their best to make compliance with their regulations difficult to achieve. Frequent changes, ambiguities, and details required for compliance open the door for the auditors to claim non-compliance and demand money retuned to the government. The vague term ‘medical necessity’ also provides much leeway for the auditors to claim “foul”. Who decides ‘medical necessity’, the provider who has actually examined the patient, or some auditor miles away, who wouldn’t recognize the patient if they saw them?

CMS has acquired a large arsenal of auditors to ensure that you comply with all the regulations. From the Recovery Audit Contractors (who are paid on commission) to the recently re-named Zone Program Integrity Contractors to the local Medicare and Medicaid reviewer, all are in place to ensure that no over payment occurs.

Don’t think that a cash practice will remove you from the threat of an audit. If you provide the patient with a receipt, which they then turn into their insurance company, you are still required to meet all state and insurance carrier regulations pertaining to documentation.Â

The solution to the nightmare of documentation and compliance with Medicare guidelines is to incorporate Electronic Medical Records (EMR) aka Electronic Health Records (EHR).Â

More on this technology and the incentives available to providers through the ARRA in next week’s article.

Submitted by Dr. DG Comfort, CO

Share

This entry was posted on Friday, September 10th, 2010 and is filed under Healthcare Reform. You can follow any responses to this entry through RSS 2.0. You can leave a response, or trackback from your own site.

No comments yet.

Cancel Reply

Welcome back Bradley K Rethwill DC. Change » Close »

Type your comment here

Categories

Business Trends

Cash Medicine

Healthcare Reform

Practice Management

Regulatory Compliance

Trends

Archives

September 2010

August 2010

July 2010

June 2010

May 2010

April 2010

March 2010

February 2010

January 2010

December 2009

November 2009

October 2009

Physiciantrends.com

HOME ABOUT PRIVACY POLICY TERMS OF USE

Medical Web Design and Online Marketing Provided by Healthcare Networks of America