Avoid Costly Mistakes & Prevent Losses Caused by Medicare Post Payment Audits

Medicare Post Payment Audits can Cost Big

A retroactive review of claims or Medicare post-payment audit is when an insurance company looks over your account — the claims that they paid to you — on behalf of the treatment that you have given to patients, and says they made a mistake and want their money back. When they do that, it could be as little a couple thousand dollars or, in some cases, millions. This is something that could lead to serious losses and even destroy your practice, so you want to be very careful when dealing with these issues. The process typically starts with an insurance company sending a simple letter saying,” Hey, we want to look over a few patients, please send us your records and bills.” Before sending a letter, the insurance provider often does a query in their system to find something unusual about your pattern of claim submission that draws it to their attention. It could be anything! They might look for outliers, people that do a whole bunch of services at one time, or high bills.

Discrepancies in Documentation Might Lead to Recoupment

After receiving medical records from the health care provider, the insurance company compares the documentation with the codes on the claim forms that were previously submitted and paid. If the insurer finds any discrepancies in the documentation or the documents submitted do not satisfy their policies for payment, the insurer might request a repayment of overpayment from you if there is any. Failing to repay the alleged amount may lead the insurance carrier to take action against you. Often, insurance companies use the self-help remedy of offsetting the amounts due to the health care provider’s current claim submissions. This process for collecting overpayments is commonly known as recoupment. To minimize or even prevent discrepancies, it is vital for both health care facilities as well as practitioners that they invest time in billing, coding and documentation compliance.

Reasons for Discrepancies

The health care industry is transitioning from inpatient settings to outpatient. Various forces are driving treatment from acute care settings towards lower levels of care. Patient outcomes are as good or even better for patients as compared to inpatients. Typically, outpatient services are provided at a lower cost and there is increased patient satisfaction as patients want to be home. Additionally, there’s increasing availability of less-invasive treatments that allow for better and faster recoveries. For this reason, outpatient services are growing in popularity, but do so does fraud and abuse in this segment.

The past decade has seen a dramatic and continuous growth of outpatient claims with one source even noting a 33 percent overall increase. This trend is not expected to abate. Also, health care providers are making adjustments to balance revenue loss from reduced inpatient stays. While providers are seeing outpatient settings as the future of care and revenue generation, the high volumes of claims make it difficult for health plans to identify overpayments.

Common Errors that Lead to Overpayment Determination

  • Failing to comply with the medical policies – All insurance carriers frame their medical policies to be in strict compliance with the state and federal regulations. Failing to comply with these policies set forth by the insurer can have serious consequences. Health care providers need to go through and review insurance’s all-payer medical policies and implement them in their operations to stay in compliance.
  • Not documenting functional improvements – Health care facilities/providers often provide prolonged care to their patients without documenting functional improvement or if there is a need for a particular service/s. Failing to appropriately document these improvements and requirements can often raise red flags. Physical medicine codes require medical facilities to ensure documentation of one-on-one time between the provider and the patient.
  • Use of wrong codes and incorrect use of modifiers – To make things simple, certain codes have been predefined to describe the services being provided to the patient. Health care providers are required to submit these claims using these codes. Using the wrong code, such as using CPT 99203 when CPT 99201 more aptly describes the service, does not only cause an overpayment determination, in some cases, it may even lead to a fraud claim if the payer claims it was done intentionally. Improper use of modifiers can also easily trigger a Medicare post-payment audit or cause issues with reimbursement.
  • Overutilization of Evaluation and Service– An evaluation and service should only be reported when they are necessary. When providers use the evaluation and service codes and the exams are found unnecessary by insurers during audits, there are chances of overpayment determination. Also, when conducting a therapy session, providers must accurately report a one-on-one session instead of a session with two or more patients.
  • Delegation of Services to Unlicensed Personnel – When claims are submitted for improperly provided services by unlicensed personnel, the insurer can recoup the payments made towards the services received by the patient. Medical health insurance policies and state law often prohibit facilities and institutions from providing services to patients through unlicensed personnel, even if they are provided under the supervision of a licensed provider.

Medlinks Cost Containment Helps You Avoid Costly Mistakes & Prevent Losses

Medical record reviews of outpatient claims are important to ensure claims are documented and billed appropriately. Partnering with a company like Medlinks Cost Containment that specializes in medical recovery services enables health plans to get to the higher volume lower dollar claims that cannot always be accessed. Our reviews can range from validating units billed and also documented in the medical record to identifying canceled procedures that are billed but not performed.

Since high-volume errors can equate to large amounts of overpaid dollars, It is important to stay on top of the ever-increasing outpatient services. Partner with Medlinks Cost Containment today to avoid costly mistakes & prevent potential losses.

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