5 Steps to Prepare for Audits

Become Denial Proof

March 18, 2015

Category: General

All documentation dealing with Medicare is at risk of being audited, whether prepayment or post-payment. And the timeframe in which CMS can perform an audit is six years, requiring you to keep extensive archives. Once an audit is underway, you must adhere to strict deadlines for responses or risk its right to appeal.

It should be recognized that these audits are not aimed at identifying actual fraud or abuse situations. The audit regimen for Medicare and Medicaid, in particular, has become focused on identifying technical deficiencies in supporting documentation and demanding refund of the payment. It’s a means to minimize spending, whether justified or not. You need to be aware of this and be prepared defend your payments. This is money that you have earned, and you shouldn’t let an administrative error keep you from getting it.

This has become part of our mission at MedFORCE: helping clients succeed giving you the confidence that no critical activities or documentation will fall through the cracks.  Based on our deep experience in this area, we have come up with 5 steps to help ensure your organization is denial-proof.

1. Deliver your product or service appropriately  - The first step to creating a denial-proof file is familiarity with the provider manual and all regulations that affect your service or product. This ensures you will provide the service or product in a way that guarantees you will be reimbursed. Control of expectations such as delivery dates, co-payments, and issues that directly affect the beneficiary is crucial to avoid complaints and reduce conflict with referral sources.

2. Be familiar with the product-to-payment path  - It sounds simple, but knowing the steps needed to get from providing the product or service to payment is essential. Before you take action, you need to know what actions to take and how to do them correctly. This includes knowing what documentation is required to support each step. A line of sight from start to finish will make sure you stay on track.

3. Create a consistent process  - Eliminate potential human error, identify and remove bottlenecks, and minimize the risk associated with employee absence by having a standard process in place for everyone to follow. A well-planned process saves time and effort by gathering and organizing what is needed at the time of service, rather than having to backfill later.

4. Train your employees  - All personnel should understand the process and all requirements. They need to be closely reviewing documents for accuracy and pay particular attention to areas/issues that may have caused problems in the past. We even suggest taking training a step further and including adherence to process as a performance requirement for employee reviews. This not only highlights the strategic importance of a consistent workflow, it also aligns employee and organization incentives.

5. Perform internal audits  - You should periodically review files for accuracy and completeness. A well-documented and implemented internal audit process will catch any errors or incomplete files before it reaches the demanding CMS audit phase.

Technology can be an incredibly powerful tool in standardizing and automating your systems and helping you tackle all five of these important precautions. Without it, traditional offices can be forced to invest many man-hours in finding, copying and preparing documentations for audits. Misfiling or variances in how employees complete vital steps can be costly. And then there is the added challenge of tracking audit results and following up.

Due to the large quantity of often-changing rules, having a central workflow that requires users to follow the correct steps for each product line or service is the best way to ensure the needed documentation will be on file to support payment in an audit. A solid software program will also enable the automation of specified steps, reducing opportunities human error. Electronic filing enables quick and easy retrieval of any documentation in question, while an esMD portal can save time and headache with the actual submission process. At the management level, analytics dashboards and admin controls allow you to get a real-time read on the efficacy of your operations and identify opportunities to mitigate risk.

We urge everyone to make sure you have the proper processes in place to understand requirements, meet expected deadlines, retain specified documentation, and maintain a proactive stance in ensuring workflows are running smoothly. Don’t wait until the heightened state of an audit to understand how well your operations are functioning. Become denial-proof today.

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