Audits are no longer just for large payors, provider groups are feeling the pressure of rising compliance audits, and the playing field is complicated to negotiate. Some of this may seem unfair, but with the cost of medical fraud on the rise, the DOJ, CMS, OIG, HMS and all the other initials are not going to let up any time soon, if ever.
The DOJ sued Cigna in October, the Supreme Court refused to intervene on behalf of Molina Healthcare’s whistle-blower case, and more negative audit and antitrust cases are appearing daily.. You may be doing your best but that is no defence in an audit. The only things that matter are facts, documentation, accuracy, and pure compliance. Practicing medicine is an art, but documenting is a strict science, and anything less than precise documentation may result in poor audit outcomes and your company’s name up next in the headlines.
The DOJ is relentless, but not unpredictable. It turns out, they consistently target the same set of codes in nearly every suit. Apparently, the “low-hanging fruit” can be bucketed into four simple categories: Acute coded as chronic; Lack of clinical accuracy or supporting documentation (MEAT Criteria); and Diagnosing without changing the plan of care.
We’ve pulled together a list of “The Usual Suspects” – HCC codes that appear most frequently in DOJ audits, and married the specific codes with strategies to both find them in your EMR and avoid them in your coding. Access the most common offenders in our free report.
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Learn How To
- Identify codes most commonly identified in DOJ audits
- Implement three best-demonstrated practices to improve compliance
- Discover resources and tools to improve compliance and harden against negative audit outcomes