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Proper documentation can protect you in an audit
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ATLANTA – Knowing and following your local and national coverage determinations and the American Academy of Ophthalmology’s Preferred Practice Patterns could help your practice successfully survive an audit from a CMS recovery audit contractor, according to a speaker here at SECO.
Recovery audit contractors (RACs) detect and correct past improper payments so that CMS and insurance carriers can implement actions that will prevent future improper payments, Carl Spear, MS, OD, MBA, said.
“It’s a new world for medical billing, and you must understand the system,” he said.
Utilization is the biggest factor that drives audits, Spear said. Another important area is medical necessity, which is based upon Medicare manuals, national and local coverage determinations (NCDs and LCDs), professional guidelines and peer-reviewed research.
A Medicare administrative contractor (MAC) works for the government in a certain geographic area to establish payments, Spear explained.
Carl Spear
“There are 12 MAC regions, with eight companies doing it,” he said. “Know your MAC and LCDs and NCDs.”
Another entity with which ODs should be familiar is the zone program integrity contractor (ZPIC).
“If you get a letter from a ZPIC auditor, contact your attorney immediately,” Spear said. “The Federal Bureau of Investigation or Department of Justice may already be involved and pretty far down the line in believing that you’ve committed fraud.”
Spear said that RACs conduct three types of audits: automated (computerized), which is usually done on a random basis; semi-automated, which marries a computer-generated audit with requests for records and documentation; and complex, where the RAC sends you a letter asking for some records.
“They look for a pattern,” he said. “If they see one you get added to the provider audit list. Then they ask for 30 records.”
If you are contacted regarding an audit, “talk to someone who knows what they’re doing before you submit the paperwork,” he said. “Remember, the RACs get paid 20% on what they collect. If they go through the first three or five or 10 and the records are pretty clean, they won’t waste their time.”
If you are audited, however, “never, never, never make a change to a record,” Spear cautioned.
In 2014, RACs took 971 criminal actions and 573 civil actions, he said. They also recovered $5 billion as a result of audits and investigations.
“This is a money making machine,” Spear said. “They spend $400 million and collect $5 billion. This is the best run area of the government. This a very focused organization that’s targeting you and me.”
Spear listed good and bad words and phrases to use in medical records.
Good words include possible progression over time, new problem (especially in existing patients), pain, chronic and change.
“The more specific you are the better,” Spear said. “I think that ICD-10 will be a good thing for us. It will be painful initially, but because of the specificity you have to get into, it will help us be better documenters.”
Bad words include rule out, stable, no change, check glasses, no symptoms and no problems, he said. – by Nancy Hemphill, ELS, FAAO