Internal investigations of billing issues usually involve audits. It is important to approach an audit carefully or the auditors can create more risk for the organization by misinterpreting the standards.
Thus, it is very important to know what you are auditing before you audit. It seems simple but this is often overlooked. Fully researching all the issues involved with a critical eye is key. There may be subtle changes in coding, billing or coverage policy or guidance that caused confusion. There actually may be little reimbursement impact from the error.
After the regulatory scope and applicability are researched an audit protocol should be drafted. The protocol should be carefully worded and tied back to the research. There should be an expectation that the government or opposing party is going to obtain a copy at some point in the negotiation. If an attorney does not draft the protocol, they should review it for language.
If there also is a government or payer review ongoing, review the same records and make your own findings. If you are the one doing the audit as part of a settlement or potential repayment, the size of the audit sample and timeframe is very important. Usually the best course is a smaller sample called a probe audit that restricts or expands the audit as issues are found to have either continued or have resolved.
Creating an audit report for negotiation is important. Overpayments as well as underpayments should be included as offsets are allowed and even specifically referenced in Medicare manuals. The report should include a concise argument for the regulatory position you are taking with regard to coding, contracting or manual provisions.
The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.
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