ED Coding & Reimbursement Alert - 2019 Issue 5
OIG Report: Make Sure You’re Ready for CMS’s Audit Spotlight
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Article Overview
This article summarizes an HHS Office of Inspector General report about CMS’s handling of audit recommendations and the broader implications for Medicare claim oversight. It is aimed at medical practices, coders, billing staff, and compliance professionals who want to understand the kinds of audit-focused areas that may draw attention, including utilization patterns, relative value reporting, modifier usage, and reported time. The piece also places the discussion in the context of CMS audit tools and provider self-review readiness.
Why This Topic Matters
The article helps readers recognize the compliance areas that may become more closely scrutinized as CMS strengthens audit resolution and enforcement processes. It is relevant for practices trying to assess audit risk and improve internal review processes before claims are challenged.
Article Sections
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Understand the Problem
Summarizes the OIG report’s concerns about CMS audit-resolution timeliness and notes the reported response from CMS. It also frames the broader compliance and oversight context for providers.
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Expect Review of Key Areas
Introduces the main audit focus areas discussed in the article, including claim frequency, procedure utilization, relative value reporting, modifier review, and reported time. The section also references CMS audit tools and provider self-assessment considerations.
What You Will Learn
- How an OIG report may influence expectations for CMS audit activity
- What general claim and utilization areas are commonly reviewed in audit settings
- Why providers may want to compare their billing patterns with broader Medicare data
- How modifier use and time reporting can become audit attention points
- What types of CMS audit tools and enforcement trends are discussed in relation to Medicare claims
Who Should Read This
- General surgery practices
- Medical coders
- Billing and reimbursement staff
- Compliance officers
- Practice managers
- Healthcare auditors
Codes Discussed
Modifiers Discussed
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