Be Prepared For The Future

Prior blogs ahev emphasized the importance of periodic sample audits performed internally of with consulting help. The Center for Medicare Services (CMS) has stated: “A self-audit is an audit, examination, review, or other inspection performed both by and within a given health care practice or business. Self-audits generally focus on assessing, correcting, and maintaining controls to promote compliance with applicable laws, rules, and regulations. The U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG) advises periodic internal monitoring and auditing among its list of the seven elements of a sound compliance program. Self-audits can help: (1) Reduce fraud and improper payments; (2) Improve patient care; (3) Lower the chances of an external audit; and (4) Help create a robust culture of compliance." Obviously they take the self audit seriously.


So you have prepared your organization by performing a self-audit as CMS has advised using the toolkit it has made available. What now? Experts say that it isn’t a matter of “if” you will be audited “it is a matter of when”. The self-audit is only the beginning. Monitoring is an ongoing effort “to ensure that policies and procedures are in place and are being followed.” It should be part of your normal daily activity and operations. Being prepared is by far your best position.

As things change, since nothing remains the same, consider for future audits when there are changes in:

  • Codes (ICD10, HCPCS, CPT)
  • Local Coverage Determinations (LCD)
  • National Coverage Determinations (NCD)
  • Contractor (Both federal and commercial)
  • New provider joins the group
  • Identification of ANSI denial increases
  • Medical record request from contractors (Both federal and commercial)
  • And the list just keeps growing

On a routine basis, the bare minimum is every year for every provider unless your “special” audits for any of the above demonstrate a potential area of concern.


Nick Henson is Senior Consultant of Medical Practice Consultants MPC. For over 24 years, MPC provides its clients with a  comprehensive understanding of the complete reimbursement process, documentation, coding, and the ability to challenge and prevail in claim appeals with CMS carrier and program integrity contractors. Our clients have  peace of mind knowing that their billing and performance evaluations insure demonstrable current complience.


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