The Best Offense for Appeals: A Good Defense

One of the best strategies against an audit and possible appeal is prevention.

One of the best strategies against an audit and possible appeal is prevention — making sure your processes are created and maintained to produce a claim that is virtually audit-proof. Wayne van Halem, President of The van Halem Group, recently held an HME Business University webinar titled, Top 10 Audit Tips. He suggested:

Have a compliance program that meets all of Medicare’s requirements. The elements you need to have in place to consider your program is valid include:

  • Policies and procedures
  • Compliance Officer/Committee
  • Internal audits
  • Targeted education and training
  • Publicized and utilized disciplinary guidelines
  • Timely response to issues/offenses

Look at your data — 95% of audits are direct results of data analysis. Medicare will focus on:

  • Spikes in billing
  • NPI concentrations
  • Maximum allowed amounts
  • Diagnosis codes
  • Accessories
  • Risk assessments

Develop an internal quality assurance/prescreen process. Look at it from a reimbursement standpoint, especially at the high-risk codes. Make sure to:

  • Use checklists
  • Implement a prior approval process
  • Track errors and issues
  • Perform education and training
  • Implement corrective actions or disciplinary standards

Listen to the webinar to get important details and hear all his top tips. Don't delay, this webinar will only be available until January 13, 2016.

This article originally appeared in the January 2016 issue of HME Business.

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