Since the start of the Medicare Recovery Audit program in 2009, audits have become a regular part of healthcare payments. From 2009 to 2014, the program recovered more than $8 billion from Medicare claims that had errors. These errors included incorrect coding (42%), medically unnecessary services (32%), and missing or poor documentation (9%). Third-party contractors usually handle these audits by looking back at claims and finding overpayments or underpayments.<\/p>\n
Recovery Audit Contractors (RACs) get paid based on the amount they recover. This encourages them to work harder at finding overpayments, so audits happen more often. Providers in states like Florida, which have more healthcare fraud cases, face a higher chance of audits. Practice owners and administrators need to stay alert.<\/p>\n
Other groups that do audits include Medicare Administrative Contractors (MACs), Medicaid Integrity Contractors (MICs), Zone Program Integrity Contractors (ZPICs), and private insurance companies. MACs do both prepayment and postpayment checks and sometimes do special \u201cprobe audits\u201d if they suspect problems. ZPICs mainly look for fraud, waste, and abuse, which can bring serious legal trouble.<\/p>\n
Private insurance companies also do audits, but they usually check claims soon after the patient visit. They sometimes do prepayment audits, which means they hold back payment while they review the claim. These audits may start because of frequent billing mistakes, strange payment patterns, or tips from whistleblowers.<\/p>\n
Healthcare providers should know what usually causes audits to happen. This helps them get ready and avoid problems. One main cause is frequent billing errors. These include repeated mistakes with modifiers, wrong coding of services, and sending the same claim more than once.<\/p>\n
Claims with large dollar amounts may get more attention. Especially if the paperwork does not clearly explain why the services were needed or does not follow payer rules. Advanced data methods also look for claims that are very different from normal patterns. Providers with a high number of claims for certain services might be checked more closely.<\/p>\n
Missing or incomplete documentation often causes audits. Auditors want detailed medical records that explain why the billed services were done. This includes the clinical reason, what was done, and the results. Without good documentation, claims can be denied or money can be asked back.<\/p>\n
<\/p>\n