decisionhealth Newsletters, Part B News - 2000 Issue 10 (October)
Do you know your carrier's audit criteria? Here's how to find out
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Article Overview
This article explains general ways physician practices can identify the criteria their carrier uses for audit selection, including who to contact, what kinds of data may be available, and where to look for broader audit information. It is aimed at doctors, billers, practice managers, and compliance staff who want to understand audit activity, carrier review patterns, and public sources of audit-related guidance. The discussion also references Medicare carrier processes, carrier education and provider-relations resources, and use of federal information requests as a fallback source for audit criteria.
Why This Topic Matters
Understanding audit triggers can help practices prepare for review activity, interpret carrier feedback, and find the right internal or public source for audit-related information.
Article Sections
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How practices learn audit criteria
Introduces general ways practices can find out what information carriers use when selecting claims or providers for review. Covers contact strategies and the types of carrier personnel who may help direct questions.
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Why audits may be triggered
Discusses broad reasons audit activity may occur, including unusual utilization patterns and computer-generated review processes. Also touches on carrier-side comparisons and state-level patterns.
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Random audits and patient verification
Describes the article's discussion of random audit activity and related information requests. Also mentions situations where patient confirmation may be used as part of the review process.
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Carrier feedback, education, and public-record requests
Summarizes the article's coverage of carrier obligations to provide audit-related feedback and the use of public-information requests as a backup approach. Includes references to Medicare guidance and federal information access methods.
What You Will Learn
- Ways to approach a carrier when trying to learn audit criteria
- Common channels within an insurer that may help locate audit-related information
- General categories of audit activity and review triggers
- How audit feedback and comparative information may be obtained
- Alternative public-information methods for requesting carrier data
Who Should Read This
- Physicians
- Medical billers
- Practice administrators
- Compliance staff
- Revenue cycle managers
Codes Discussed
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