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by Antonio Arias, MBA, CHBME

Why Your Practice Needs A Risk-Based Audit Plan


Following the implementation of the new 60-day payback and six-year lookback requirements, it’s clear the government has higher-than-ever expectations of practices when it comes to self-policing overpayments.

But that’s far from the only area of risk facing providers when it comes to liability.

As healthcare continues to evolve (with a mind for value in care and fairness in payments), audits are expected to take place at a faster and faster clip in coming years. Practices should expect every aspect of their operations to be subject to scrutiny – from coding accuracy and incentive-program participation to end-to-end billing and compliance.

Is your practice prepared for a potential audit? Or perhaps more importantly, do you know what areas of your operation could put you in hot water if an audit were to take place?

If your answer to the above questions is “no,” then it’s time to put an action plan in place. According to healthcare consultants, the government has been using predictive analytics to identify high-risk targets for fraud, financial mismanagement, and inaccurate billings.

Thanks to the ever-growing volume of administrative data at their disposal, the efforts of CMS and regulators are growing ever more sophisticated, drilling down to the particular codes and modifiers that can be indicative of inappropriate activity (and pinning down which physicians may be abusing them).

Even if you’re certain there’s no misbehavior at your practice, it’s important to identify your areas of risk and respond them now. Self-auditing can illuminate areas of risk, but it’s often done with a random selection of charts spanning all of your providers, patient groups, and staff members.

That kind of needle-in-a-haystack approach can allow risk areas to go unnoticed or under-respected, even while they absorb resources that could be better spent on a targeted approach. A highly effective strategy involves looking at your data holistically, assessing it for problem areas, and then self-auditing only the most risk-saturated physicians or charts.

If you’re working with a trusted medical billing firm, your administrative data is available to you in the same manner it’s available to the government bodies who may audit you down the line (should their algorithms sniff anything irregular in your RCM results).

Working with a consultant or billing service to run your de-identified data through predictive analytics can help you attack any areas of risk, self-report any issues you spot, and invest in the corrective measures – repayments, fines, and so on – that can minimize your liability.

All in, that kind of precision, risk-based audit plan can cost you less money than an end-to-end self-audit… and better protecting your practice from regulatory scrutiny in the process.


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...and if you need help from a medical billing company...


by Antonio Arias, MBA, CHBME

Want to see how outsourcing medical billing can help your practice? Contact a billing expert at NCG Medical today!

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