SEP 21, 2017
Two Ways Practices Trigger Their Own Audits
The Centers for Medicare and Medicaid Services conducts two types of recovery audits: 1) Some seeking data; and 2) Some requesting records for a more complex review. Practices’ own actions sometime prompt one of these two audits.
In two recent cases, the practice’s own errors in billing triggered data driven audits.
Case 1: Injecting anti-VEGF drugs sooner than the FDA-approved 28 days in the same eye.
If you’re audited:
- Contacts at CMS confirm you have a little leeway.
- Medicare administrative contractors may deny claims.
- If the date of service between exams is 25 days or less, you may receive a data-driven audit.
How to protect your practice:
- Remind those who schedule follow-up appointments to literally count 28 days between injections to meet all payer requirements.
- If it’s medically necessary to inject sooner, have the letter of medical necessity ready for your appeal.
Case 2: Billing a new-patient exam after the patient has already undergone testing services in the office.
Why the audit happened: Once any claim has been received for any service, the patient is now an established patient of the practice.
If you’re audited:
- The practice may have to repay the new patient exams. In this case, the audit did not ask for repayment of the testing services.
- Once you identify the billing error, schedule an immediate phone review (or whatever process they require) with the MAC to correct all exams submitted within the last 12 months. Make sure the fix applies to all exams billed as new when they were actually established patients of the practice.
- Repay the difference immediately to avoid more data-driven recoupments.
How to protect your practice:
- Follow the payer protocol, going forward. The physician must first examine new patients and only then order any testing services as medically indicated.
When you follow this protocol, you can bill a new patient exam.