HIM departments face scrutiny from growing number of auditing bodies

Why This Topic Matters

Understanding these audit programs helps healthcare organizations anticipate review activity, strengthen documentation and compliance processes, and better align coding and CDI operations with federal oversight expectations.

Article Sections

1. Overview of auditing bodies and compliance pressure

   Introduces the broader compliance environment and the main categories of federal and contractor oversight affecting healthcare reimbursement and documentation.

2. Watchdog programs created by CMS and related entities

   Summarizes the major oversight and review programs discussed in the article and how they fit into Medicare payment integrity efforts.

3. CERT

   Describes the CERT program’s role in postpayment review, sampling, and reporting of Medicare fee-for-service payment error data.

4. MACs

   Covers the claims-processing and payment integrity responsibilities of Medicare Administrative Contractors, including claim adjustments and review activity.

5. PEPPER

   Explains the use of comparative reporting to identify risk areas and outlier patterns for hospitals and coding departments.

6. Recovery Auditors

   Discusses the Recovery Auditor program, its review focus, and its relationship to overpayments, underpayments, and facility preparation for audit activity.

7. QIOs and query-related issues

   Reviews the role of quality oversight organizations and the article’s discussion of record review, medical necessity, and query handling concerns.

8. SMRC

   Outlines the nationwide medical review function performed under CMS direction and the follow-up process for identified payment issues.

9. ZPICs

   Covers Medicare program integrity investigations tied to fraud concerns and the service areas affected by these reviews.