What The Police Can Teach Providers About Audits

In 1982, Sting wrote a song that can best be described as.....stalkerish. The song went on to be a hit and is widely considered one of the greatest songs ever. Sting has stated "I think the song is very, very sinister and ugly and people have actually misinterpreted it as being a gentle little love song, when it's quite the opposite." Source. When reading the lyrics for the first verse, I agree with Sting

"Every breath you take and every move you make
Every bond you break, every step you take, I'll be watching you
Every single day and every word you say
Every game you play, every night you stay, I'll be watching you"

Courtesy of MetroLyrics.

So, how does this apply to audits? Very simply. Sing it with me, "Every claim you submit and every patient record you provide, CMS or private insurance companies will be reviewing them." I know it isn't as catchy as hearing Sting's wonderful voice sing those creepy lyrics, but you get the point. By the way, these reviews can be done independently(you agreed to that in your provider agreement), or can be done as part of a records request.

In an independent review, Medicare or private insurance companies review claims and determine if the submission of certain CPT codes are higher than that of other similar providers across the nation. If yes, an overpayment letter may be issued.

In a records request, CMS(actually one of its MANY contractors) or private insurance companies send a letter requesting certain patient records over a certain time period. If the documentation does not support the CPT code, the claim will be retroactively denied and an overpayment letter will be issued.

In the case of CMS, after all the submitted records will be reviewed, the number of claims denied from the requested period will then be extrapolated over the total universe of claims. Normally, the result of this extrapolation is a big, (insert word of choice) overpayment. For example, in one case, an actual overpayment amount of around $160,000 was extrapolated to over $6,000,000.

To fight this overpayment and extrapolated amount, the government has provided a 5 stage appeal process. In our experience, this extrapolated amount is extremely difficult to set aside, but it can be done.

So, in summation, when you submit claims, remember these claims will be reviewed not just at the initial payment stage, but also later on. Because....."CMS or private insurance companies will be reviewing them."