How To Protect Your Organization From E/M Claims Scrutiny

Healthcare fraud and abuse has the Department of Health & Human Services on the offense, poised and ready to strike. They’ve put measures in place to boost quality of care while reducing the government’s spending. Now, more than ever, your risk of being audited is real and the necessity for accurate documentation is crucial. Luckily, preparing for E/M claims scrutiny doesn’t have to be as daunting as it sounds.

The first step to protecting yourself from E/M claims scrutiny is to educate yourself. The more up-to-date you are, the easier it will be to find and correct potential errors in your practice before an auditor does. Prevention can save your organization both time and money.

Start with Published Audit Reports, Compliance Facts, and Medicare Updates

Find where previous improper payments were found and apply those “lessons learned” to your own organization.

Here's some great resource links for published audit reports:

• RAC findings: www.cms.gov/rac
• OIG reports: www.oig.hhs.gov/reports-and-publications/index.asp
• CERT reports: www.cms.gov/cert

Bookmark the CMS’ Provider Compliance Webpage

On the CMS' Provider Compliance Webpage, you’ll find Medicare Learning Network® (MLN) educational products, such as “Compliance Fast Facts” and the “Medicare Quarterly Provider Compliance Newsletter.” Use these resources to help educate your providers about common billing errors and how they can avoid improper payments. This page also includes online training courses.

Sign up for CMS Connects™ provider e-news, published every Thursday, to receive important notifications of Medicare updates and CMS national provider calls.

Understand CERTs' Top E/M Error Codes

The improper error rate published in the 2014 CERT Report (November 2014) was 12.7 percent, which represents $45.8 billion in improper payments. E/M services accounted for 9.3 percent of the overall Medicare fee-for-service improper payment rate, representing approximately $4.5 billion in improper payments.

CERT errors are categorized into five error types:

1. No documentation
2. Insufficient documentation
3. Medical necessity
4. Incorrect coding
5. "Other” errors

E/M errors were mostly due to incorrect coding and insufficient documentation. Incorrect coding results when claims are down-coded because the documentation does not support the code paid. Insufficient documentation often results from lack of physician authentication or the physician not obtaining the additional documentation required.

Stay On Top Of Regulation Changes

The best defense is a solid offense; fully educate yourself in the RAC Appeals Process. While the RAC program was paused for a time, it is now back in full swing. The FY 2014 Report to Congress for the Recovery Auditing in Medicare provides insight which is helpful for physicians as Medicare Part B providers to know.

For more information on how you can protect your organization from E/M claims scrutiny, and where auditors focus their attention, download our free eBrief, 11 Simple Ways To Prepare For E/M Claims Scrutiny, by clicking the button below: