decisionhealth Newsletters, Part B News - 2013 Issue 8 (August)
8 trouble spots on claims you can check to avoid denials, save money
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Article Overview
This compliance-focused article explains how practices can use chart reviews, spot audits, and claim monitoring to identify areas that may attract contractor scrutiny or denial risk. It is aimed at physicians, coders, auditors, compliance staff, and practice managers who want to understand the main categories of billing and documentation issues that should be reviewed regularly. The discussion covers broad audit areas, including evaluation and management utilization patterns, medical necessity denials, incident-to billing, test interpretation documentation, supply costs, specialty-specific risks, physician spot-checks, and OIG Work Plan-related concerns.
Why This Topic Matters
Regular internal review can help practices catch patterns that lead to denials, audit exposure, and lost reimbursement before they become larger compliance problems.
Article Sections
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Compliance
Introduces the article’s focus on audit readiness and the use of chart reviews to identify billing and documentation concerns. Sets up the broader compliance context for the issues discussed later.
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E/M: The big one
Discusses evaluation and management utilization patterns and the role of comparing physician billing patterns against internal and external norms. Also touches on the use of outside review when unusual patterns appear.
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7 more audit focus spots
Summarizes additional claim-review areas practices may want to monitor as part of routine audits. Covers a range of billing, documentation, reimbursement, and compliance topics relevant to ongoing oversight.
What You Will Learn
- How internal audits can help identify claim patterns that may draw contractor attention
- Why evaluation and management utilization is often reviewed in compliance audits
- What broad billing and documentation areas are commonly included in regular spot checks
- How practices may think about specialty-specific risks and recurring denial patterns
- Why monitoring external guidance and work plans can be part of audit planning
Who Should Read This
- Physicians
- Medical coders
- Compliance staff
- Practice managers
- Auditors
- Billing staff
Codes Discussed
Modifiers Discussed
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