decisionhealth Newsletters, Part B News - 2011 Issue 3 (March)
MACs, other auditors allowed to data mine your claims history during complex reviews
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Article Overview
This piece summarizes CMS guidance in Program Integrity Manual transmittal 367 about when Medicare auditors may consider claims history during complex reviews and related program integrity work. It is aimed at providers, compliance staff, and coders who want to understand the kinds of documentation and utilization issues auditors may investigate, including when additional records from other providers may be sought.
Why This Topic Matters
The article matters because it describes how auditors may use prior claims information to assess payment appropriateness and identify potential duplication, overutilization, or documentation support from other sources. That affects compliance, inpatient documentation practices, and how organizations prepare for medical review.
What You Will Learn
- How CMS describes auditor access to claims history during complex reviews and related audits.
- What broad situations may justify looking at claims history during a review.
- Why documentation patterns in the inpatient setting may draw auditor attention.
- How claims history considerations can affect medical review preparation and compliance practices.
Who Should Read This
- Medical coders
- Billing staff
- Compliance officers
- Revenue cycle professionals
- Physicians and provider groups
- Hospital inpatient documentation staff
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