This week, NCMS EVP/CEO Robert W. Seligson, NCMS President Robert W. Monteiro, MD, and former NCMS President Richard Bruch, MD met with U.S. Senator Richard Burr in Washington. One key item discussed was the potential for federal legislation that would introduce a set of fair audit principles into various Medicare and Medicaid program integrity audits and initiatives.

The conversation with Senator Burr follows the release of “Guilty Until Proven Innocent: When Medicare Audits Cause Casualties,” a documentary produced by NCMS that reveals the plight of rural North Carolina physicians who are forced to spend months of time and thousands of dollars to overcome an unfair, biased Medicare audit.

Along with the Physicians Advocacy Institute, Inc. (PAI), the NCMS produced “Fair Audit Principles” to promote fairness and transparency when federal contractors audit medical practices. PAI and NCMS highlight the following points that would reduce the amount of inaccurate medical audit findings:

Advance notification. Auditors should provide physician practices with advance written notice sent by certified mail at least 30 business days before a medical audit. The notice should clearly identify all information surrounding the audit, including which legal authority the audit is being conducted.

Schedule the audit. If the audit is to be conducted at physicians’ offices, it should be scheduled at a mutually convenient time.

Qualifications of auditors. All individuals performing medical audits should have appropriate knowledge and experience in all aspects of medical coding.

Conduct of the audit. The audit should be limited to claims submitted within 18 months of the date of the audit, unless a shorter time is dictated by law. Auditors must agree to protect personal health information. Auditors also should recognize the physicians’ need to provide continuity of care to patients. Auditors should advise physicians to review the records before submission and those that are taken for review by the auditors should be copies, not originals. It also is key that auditors set up a process to allow auditors and physicians to discuss the medical records before submissions are completed.

Audit Report. The audit report should clearly identify any errors discovered in the audit, specifically all medical reimbursement policies used in determining the outcome of the audit.

Extrapolation. If extrapolation is used to calculate an alleged overpayment amount, this should be noted in the audit report.

Appeals. The entity responsible for the initial audit review, whether it be a health plan or an outside contractor, should be responsible for handling a physician practice’s initial request for reconsideration.

The NCMS fully supports the development and passage of federal legislation, and we will continue to work toward improving the methods used in medical audits. Look to future issues of the Bulletin for updates. For more information regarding fraud and abuse, click here. PAI’s recently published, “Medical Audits: What Physicians Need to Know,” also is a great resource for those physicians who have questions concerning medical audits.