Auditing

60 Day Final Rule

Effective March 14, 2016, the CMS Final Rule regarding the reporting of overpayments took effect. This ruling clarifies the standards that have been unclear for years since the the PPACA created what is called the "60-day rule." The problem has been the unclear standards on what it means to "identify" an overpayment and when the 60 day clock begins running.

Now, the 60-day rule requires anyone who has received an overpayment from either Medicare or Medicaid to report and return the overpayment within the latter of:

NAMAS Weekly Auditing and Compliance Tips

Combined Deskbook Resources

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Employee Exclusions Screenings Must be High Priority

Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. The OIG is reviewing organizations in ALL federal healthcare programs - this includes Medicare, Medicaid, CHIP, etc. - for those who have employed individuals on ANY exclusions database. Not only must you screen employees on the OIG Exclusions database, but employers are also responsible to check state exclusions databases as well.

When documenting the history components in an Evaluation and Management service, the clinician is not required to use the headings that the Documentation Guidelines define.  That is, the history section does not need to be labeled: History of the Present Illness, Review of Systems, and past medical, family and social history.  The auditor may use history found in any part of the history.  The ROS may be in a section labeled as ROS or it may be part of the HPI.  

Audit Resources (Resource 302)

Understanding Compliance and audits and being prepared for them can be helpful. Generally, healthcare provdiers need to understand:

Tip: Audit Fighting Tactics

When you are audited or have your claims reviewed here are some fighting tactics that are effective and easy to use:

Refund Demands and Contracts

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Refund Demands and Contracts

All refund demands from payers are not alike. Some could be justified. Recently a payer asked for a refund request from a ChiroCode subscriber. She said: “We sent the No Refund letter from ChiroCode. However, they ignored it and they still want a refund. What do I do next?”

What To Do When a Payer Audits You

When a payer audits you the first thing to do is respond to the audit. Do not ignore it; it won’t go away. In the initial stage of the audit, they will probably ask you to send them your notes on approximately 5-10 patients. Either have a health care attorney or yourself send exactly what they want in a timely fashion. Delaying, or not sending the notes, might lead the insurance carrier to think that you are hiding something.

Send nothing more and nothing less than what they ask for.

Was Your Claim Denied as a Duplicate Service?

On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?

First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the claim may be denied as duplicate:

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