2025 Gastroenterology Reimbursement and Coding Update (Virtual) | November 2024-09 - Auditing_Physicians_and_APPs_In_Your

09 - Auditing_Physicians_and_APPs_In_Your_Practice

Pdf Summary

The document "Auditing Physicians and Advanced Practice Providers in Your Practice," presented by Kristin Vaughn, focuses on guiding healthcare providers through the complexities of coding, billing, and payer audits. Key aspects of the presentation include:<br /><br />1. **Provider Education**: Effective education and communication with providers is essential, especially as many are not comprehensively trained in specialized billing and coding practices, such as gastroenterology (GI) coding.<br /><br />2. **Audit Risk and Benchmarking**: Providers need to understand Evaluation & Management (E&M) codes and ensure their usage aligns with benchmarks to avoid audits. Discrepancies between practice patterns and benchmarks can trigger payer audits.<br /><br />3. **Types of Audits**:<br />   - **Office of Inspector General (OIG)**: Focuses on preventing fraud, waste, and abuse across various healthcare entities.<br />   - **Recovery Audit Contractors (RAC)**: Identifies and recovers improper Medicare payments.<br />   - **Certified Error Rate Testing (CERT)**: Monitors claim accuracy to protect the Medicare Trust Fund and identifies documentation errors.<br /><br />4. **Responses to Audits**: Properly addressing audit notices and working with health attorneys can help mitigate risks. Key actions include providing complete, legible records and summaries when necessary, avoiding record alterations post-audit notice, and maintaining detailed documentation of communication and submissions.<br /><br />5. **Medicare Audit Strategies**: Providers should genuinely react to audit letters, adhere strictly to requested information provision, and not hesitate to engage a health attorney. Retaining meticulous copies, documenting care adequately, and explaining unusual practices or missing entries are crucial for responding effectively to audits.<br /><br />Understanding these principles aids healthcare facilities in maintaining compliance with Medicare and other payer requirements, thus preventing legal issues and financial penalties.

Keywords

healthcare audits

provider education

coding and billing

E&M codes

audit risk

OIG audits

RAC audits

CERT audits

Medicare compliance

audit response strategies