• Medicare Claim Audits and the Steps to Compliance

    August 31, 2017 | Kevin Kasmar
  • Therapy facilities get a little nervous when the discussion turns to Medicare fraud. A medical claims audit may drudge up things you don’t want to hear. The goal of a post- or prepayment audit by Medicare is not to cause distress. The goal is to provide healthcare workers with instruction and goals to ensure their compliance. This article describes the different types of audits Medicare performs, and give a few guidelines that will keep your practice on the right path. 3, 2, 1…

    Three Pre-payment Claims Review Programs

    Medicare has built edits in to their electronic claims system that provide clean claim advice to providers before the payment is made.

    • National Correct Coding Initiative (NCCI) uses coding guidelines to determine which codes should or should not be billed together. Some of the pairs determined to be exclusive can be billed together with the use of an approved modifier.
    • Medically Unlikely Edits (MUEs) use claim line and specified code information to determine the maximum number of units likely for the specific treatment. This Medicare audit tool will refuse payments on line items that exceed the norm.
    • Medical Review is used both pre- and post-payment for claims from providers that have been classified through other audit means as needing minor, moderate, or severe corrective action. This Medicare audit tool first notifies of the issues detected. If the issues are not resolved, a sampling of claims will be taken, either pre- or post payment, to review with documentation and determine the magnitude of the issue.

    Two Post-payment Claims Review Programs

    After payment has processed, the Medicare electronic claims system continues to work toward the goal of correctly processed and billed claims procedures. The Medicare audit tool’s post-payment reviews are much more robust and require significantly more data.

    The CERT Program performs complex medical claims audit of all documentation to ensure the claim was paid appropriately according to Medicare guidelines. The CERT program focuses on the following error categories:

    • No Documentation
    • Insufficient Documentation
    • Medical Necessity
    • Incorrect Coding

    A concurrent group in the post-payment review process is the Recovery Audit Program. In coalition with the CERT program, they compare claims with Medicare billing instructions, National and Local Coverage Determinations, and regulations to procure overpaid monetary amounts.

    One List to Aid in Compliance

    • Avoid excessive use of the KX modifier
    • Do not bill an excessive number of codes/units for a single date of service
    • Do not bill for multiple therapists under one provider number
    • Include certifications in patients’ Plan of Care
    • Provide adequate PTA supervision
    • Comply with the 8 minute-rule and CCI edits
    • Recertify Plan of Care at appropriate times
    • Comply with LCD frequency/duration rules
    • Do not modify documentation
    • Supply records to Medicare when requested in a timely fashion
    • Have a Medicare compliance plan in place

    Medicare updates their rules on a regular basis. You’ll need CEUs or regular research to stay compliant. Having a team in place that will ensure your compliance and keep everyone on the right path is essential to success.  Visit the CMS.gov website for more information on Medicare compliance.