Accepting reimbursement from a third-party payer—whether Medicare or commercial insurance carrier—obligates you contractually to comply with audits designed to ensure proper payment,
appropriate treatment, and to detect fraud and abuse. These audits are part of doing business in the healthcare field today, but if problems are found, they can be expensive and time-consuming to remedy.

Specific to Medicare, certified compliance certificates are now voluntary, but will be required as of January 1, 2023 or “the January 1 that follows the declared end of the public health emergency (PHE) for COVID-19”, (CMS). These are required for all advanced diagnostic imaging services under Medicare Part B and need to be included in the patient EHR as part of the Appropriate Use Criteria Program. Clinical Decision Support Mechanism (CDSM) tools allow imaging centers to support the ordering providers in completing the process and thereby ensure payment for everyone.

Best Ways to Approach an Audit

When an audit has been requested, you can expect a visit from either a recovery audit contractor (RAC) through Medicare or a private payer auditor. While these audits are unavoidable, you are well served to anticipate them and be prepared to accommodate the requests when they do happen. The following suggests how to prepare for and protect yourself during a Medicare and commercial carrier audit:

  • Be sure to meet all deadlines—Medicare and most private payers will give you 45 days notice and require you to schedule within that timeframe. It’s important that you don’t miss the deadline or delay the audit (this is especially important in the event you try to appeal a decision). If those dates don’t work for a valid reason, then request an extension as soon as possible.
  • Ensure radiology reports are accurately documented—make sure corresponding orders and results are noted and include working diagnoses. Of special note: as of January 1, 2023 or later, a new issue will be the presence of certified compliance certificates for CDSM’s initiated by ordering providers but required as part of the imaging center’s records for all advanced diagnostic studies.
  • Avoid coding mistakes—auditors will be diligent in matching the level of service; including documentation supporting medical necessity, whether charges were coded to the highest level of specificity, and bundled versus unbundled.
  • Pull a sampling of patient reports for review—Before the upcoming audit, pull reports from that insurance carrier and assess your performance. If the results are less than
    outstanding, have a plan in place to present to the auditor.
  • Designate a facility representative—On the day of the audit, designate a single representative as the contact point person. They should be able to respond to all requests from the auditor and keep the process moving smoothly.
  • Educate your staff—It’s important to encourage professionalism, adhere to all HIPAA requirements, and prepare all staff and providers on how to respond to questions or requests for information should they encounter the auditor on the day of the audit.
  • Perform random internal audits—As a matter of your internal compliance program, performing random audits will ensure accountability within the center and, if you have been audited before, be sure to review the past audit results and clarify that any mistakes have been rectified.

If the audit is seeking repayment from alleged overpayments, do not hesitate to conduct your own quantitative audit. Further, if an extrapolation method was used, consider requesting a review of 100% of your records for the same period. While more than burdensome, it may demonstrate inaccuracies in the original determination and justify an appeal.

While the various insurance payers use auditing as a double check on their system, it’s also a beneficial process for the imaging center. If you have strong policies and procedures implemented and are performing routine checks of your own, then the audit process should be nothing more than a secondary confirmation that things are running smoothly.

Contact us today to schedule a CDSM demo for your imaging center or hospital outpatient facility to ensure you’re ready to onboard and implement by 2023’s AUC program deadline.