| Over the course of the past two decades, | | | | 2. Competent management of medical notes, and |
| federal and state enforcement agencies have | | | | |
| investigated medical billing incidents and brought | | | | 3. Continuous monitoring of potential audit |
| multiple enforcement actions against healthcare | | | | triggers.First, the existence of a compliance |
| practices. The list of agencies tasked with billing | | | | program may determine whether the payer can |
| compliance enforcement includes federal | | | | routinely handle the matter as an innocent |
| Department of Justice, the Office of Inspector | | | | overpayment mistake or it must be investigated |
| General (OIG) at the Department of Health and | | | | by the OIG as a potentially fraudulent act.Next, |
| Human Service, state Medicaid fraud control units, | | | | careful management of medical notes is a basis |
| and others.The number of medical billing fraud | | | | for a successful audit defense, which often |
| investigations and enforcement actions has been | | | | reduces the damages significantly and helps |
| steadily growing. For instance, according to | | | | avoiding a repeat audit a few years later.Finally, |
| BillingWiki, thirteen articles and news items were | | | | audit trigger monitoring ensures compliance of |
| published on the topic of medical billing fraud during | | | | both cumulative service patterns across multiple |
| May of 2006. In addition to growing frequency of | | | | patients and individual treatments. Real-time |
| incidents, the severity of penalties has also | | | | juxtaposition of histograms of CPT code |
| escalated from relatively non-adversarial audits | | | | frequencies between practice and national |
| and occasional return of payments to fines, | | | | averages compares service patterns and alerts of |
| suspension or loss of license, and imprisonment.Six | | | | potential compliance infringements.Individual |
| out of thirteen news items and articles about | | | | treatment compliance is ensured when no specific |
| medical billing fraud published in May 2006 involve | | | | CPT code exceeds its monthly limits, such as |
| chiropractors (BillingWiki/Compliance). The | | | | billing a 9894X on each visit, or billing a 97140 |
| remaining items are distributed more or less | | | | manual therapy in place of a manipulation code |
| evenly across such specialties as psychiatry, | | | | because it pays more, or charging for 97149 |
| gynecology, neurology, orthopedics, and aged | | | | together with 9894X, while both procedures linked |
| care. The growing frequency of audits and | | | | to the same diagnosis. In the latter example, |
| increasing severity of penalties are symptomatic | | | | performing both an adjustment and a soft tissue |
| of inadequate attention to billing compliance at the | | | | manipulation in the same part of the body for the |
| chiropractic office.An insurance company typically | | | | same complaint is illegal and a repeat submission |
| performs post-payment audit by soliciting medical | | | | of such a claim may trigger an audit.An |
| notes for a random sample of paid claims during | | | | environment of high volume of patient encounters |
| the previous year. Next, the proportion of | | | | creates thousands of possibilities to deviate from |
| inadequate medical notes defines the | | | | normal distribution of services and trigger an audit. |
| overpayment percentage. The total amount of | | | | Therefore, real time analysis requires powerful |
| overpayment is then calculated by applying the | | | | technology infrastructure and competent legal |
| overpayment percentage to all payments over | | | | coverage. Such infrastructure must handle all |
| the past six years.Billing compliance is doctor's | | | | compliance aspects together, which necessitates |
| responsibility and ignoring it often results in | | | | modern Vericle-type integrative approach, |
| practice ruin. To avoid billing audit risks, some | | | | combining billing, monitoring, and medical record |
| doctors have elected to work on cash-only basis, | | | | management components in a single and |
| collecting cash payments directly from the | | | | comprehensive system.Yuval Lirov, PhD, author |
| patients instead of submitting medical claims to | | | | of "Mission Critical Systems Management" |
| insurance agencies. However, such tactics does | | | | (Prentice Hall, 1997), inventor of multiple patents in |
| not help avoid the potential audit because patients | | | | artificial intelligence and computer security, and |
| submit requests to pay the claim to the | | | | CEO of (medical billing technologies). Vericle |
| healthcare insurance company on their own.Since | | | | delivers comprehensive practice workflow engine |
| the top two reasons for post-payment audits are | | | | that integrates patient scheduling, electronic |
| over utilization of certain CPT codes and hot line | | | | medical records (EMR), billing, transcription, and |
| calls by patients and staff, the best strategy to | | | | compliance management. It improves billing |
| manage post-payment audit risk has three | | | | performance and reduces audit risk. |
| prongs:1. Formal compliance program, | | | | |