decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 10 (October)
How to survive a Medicare audit
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Article Overview
This article explains why Medicare audits are a concern for pain management practices and outlines broad steps practices can take to organize a response. It also summarizes several Medicare audit and review programs, the kinds of issues that can trigger them, and the types of internal and external resources practices may need when preparing records and coordinating with legal, billing, and clinical experts. The piece is aimed at practice managers, coders, auditors, and clinicians who handle compliance and reimbursement issues.
Why This Topic Matters
Medicare audits can affect payment, compliance exposure, and operational workload, especially in specialties that face heightened review activity. Understanding the audit landscape helps practices recognize what documentation and support resources matter before a request arrives.
Article Sections
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Audit response preparation
General guidance on organizing an audit response, managing timing, reviewing the request, and coordinating internal records and outside assistance.
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Official resources
Pointers to Medicare and HHS-related resources referenced as background material for audit and review programs.
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Know the types of Medicare audits
An overview of common Medicare audit and review programs and the broad circumstances that can lead to review activity.
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Recovery Audit Contractors (RACs)
Background on the RAC program and its role in Medicare audit activity.
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The Medicare Medical Review Program
General discussion of medical review activity and the kinds of concerns that can prompt additional scrutiny.
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Comprehensive Error-Rate Testing (CERT)
A summary of the CERT program and its function in monitoring Medicare payment accuracy.
What You Will Learn
- Why certain specialties are viewed as higher audit-risk areas
- How to organize a Medicare audit response at a high level
- What kinds of supporting professionals may be involved in audit preparation
- Which broad Medicare audit and review programs are discussed
- What general categories of documentation and compliance issues are commonly reviewed
Who Should Read This
- Medical practice managers
- Medical coders
- Compliance staff
- Billing staff
- Healthcare attorneys
- Clinicians in pain management practices
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