7 Recommendations to Avoid Audits

On Part II of HIPAA Risks Webinar by Liles and Parker, Atty's at law presented by AMBA, they offered some practical tips to avoid being audited and fined. Not many can afford the steep fines that are assessed by being found guilty of an offense because of carelessness or fraud!





7 recommended  Questions to ask yourself.




1.  Does the claim meet the Medical Necessity requirement for payment? This is the most important question to ask before submitting the claim. If it is not medically necessary to perform the procedure and if it does not meet this criteria, the claim will be denied. 

2.  Did you provide the service?  In order for you to get paid for what you did, you have to be the one to do the service.  The nurse practitioner cannot perform the service and you get the credit for it. If there is an audit, this can be a serious offense.

3.  Coverage Requirement  If you do not know what is covered, look it up in your contract. The service you provide could be medically necessary, but if it is not covered, you will not get paid. That is a waste of your time and resources, neither of which you can afford to squander away on uncovered services. Coverages will invariably differ from carrier to carrier. Make sure you and your staff know what is covered and what isn't. 

4.  Documentation  Know what documentation is required for which carrier. This can be another area in which  insurance carriers will quickly deny claims. Properly document!

5.  Proper coding Was it coded to the highest degree of specificity?  Was it the correct code for the procedure?  Were the modifiers correct? All of these coding issues can cause claim denials...which  can mean a decrease in your income if it continues regularly.

6.  Was it billed properly?   Was it bundled when it should not have been? 

7.  Was the claim legible?  Legibility is key!   Handwriting must be legible or claims will be denied.  If a carrier cannot quickly read the claim, it will be denied. If there is an error on a record, the best way to correct it is to draw a single line through the erroneous word(s) and put the correct word above it. Date and initial your changes. Do not try to make changes on someone else't entry.  That is a red flag for fraud alert!

If there is a pattern of incorrect claims submissions, audits are more likely to happen. This could lead to the loss of your practice, bankruptcy, or other disastrous effects.

Be Audit Free! Submit claims properly by using these recommendations.
Attorneys recommended the tips, after all.

Thanks for reading.

Donna McHugh, CMRS