Medical Billing Best Practices to Avert CMS Compliance Audits

cms compliance

For the management of a healthcare institution, the words CMS compliance audit can send a chill down the spine. Medicare and Medicaid audits for billing practices are one of the scariest in the healthcare landscape. Rapidly changing regulations do not make things any easier.

If your practice overlooks a coding change or fails to keep up with the latest requirements in technology and infrastructure, you may be looking massive financial problems in the face. If the audit uncovers improper practices that are longstanding, the already reimbursed funds can be disallowed and a substantial amount may need to be paid back.

CMS compliance audits are mainly directed at healthcare organizations with a history of noncompliance or past issues with billing processes. However, a certain percentage of practices are audited at random to keep everyone on their toes. If your only strategy to avoid an audit is hoping you’ll never get picked, it simply isn’t enough. A more sensible approach is a proactive one, where even if your organization does get audited, you are well prepared.

  1.  Assume you’ll be audited:

If your practice assumes the worst and is prepared for an audit, you will sail through one if it actually happens. By assuming you’ll be audited, you’ll end up retaining important documents and keeping a check on both systems and employees. Running a practice audit is a great way to remain compliant. If you’ve done a trial run, the real deal is likely to leave your organization unscathed.

  1.  Review individual processes:

Each process in your medical billing and patient information systems will be under the scanner should a CMS audit occur. There is cross integration among multiple systems, and a change in one system can lead to a need to upgrade other systems. Changing regulations also have a widespread effect on multiple processes. For instance, a change in the coding procedure of a medical procedure will mean that every system using these new codes must be updated.

  1.  Identify discrepancies:

One of the primary things auditors are looking for are discrepancies in the information from all the different systems and processes. Your medical billing procedures should include practices that check for and eliminate any discrepancies. Technology is your friend when it comes to identifying errors. Discrepancies can be minimized by knowing where to look.

  1.  Maintain documentation integrity:

Accurate and complete health records for each patient are a critical process of medical billing and something that auditors will be examining with close scrutiny. Maintaining documentation integrity means ensuring that patient identification, amendments to health records, validation of authorship, governance of information, and validity of documents submitted for claims are all managed properly. The key to getting through an audit is demonstrating an accurate trail of patient encounters where all data has been reviewed and updated.

  1.  Document everything:

An audit will look at multiple different systems in the organization. If everything is documented, you’ll be able to demonstrate meaningful use and other evidence of EHR compliance. Documentation will allow you to justify every decision and change. It will also quickly identify problem areas that need to be addressed.

  1.  Benefit from a qualified team:

Despite your best efforts, if your team is not qualified to manage the billing at a healthcare organization, you may find yourself in trouble. A well-trained billing team with extensive experience in best practices is your best bet to avert a CMS compliance audit. Certified and credentialed billers are less likely to make errors. They have a deep understanding of the complicated processes, technology, workflow, and documentation necessary to comply with regulations. They are also aware of the latest changes in the industry and how they impact your organization. A qualified billing team not only helps avoid audits, but helps you sail through one should it occur.

Contact us to find out how we can help with your CMS compliance.

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