Frequently Asked Questions
What is the main purpose of a Medicare audit?
The main goal of a Medicare audit is to verify that providers are billing only for services that are medically reasonable and necessary. Auditors check for overbilling, improper use of modifiers, and documentation inconsistencies.
Why are physical therapists frequently audited?
Physical therapists often use the KX modifier to bypass therapy caps, which triggers scrutiny. Additionally, billing a high number of codes per visit or failing to meet documentation standards increases the likelihood of an audit.
What documentation issues raise red flags during a Medicare audit?
Auditors closely examine missing or improperly applied signatures, rubber-stamped or electronic-only approvals, and insufficient documentation that doesn’t support the billed services. These can all suggest that services were improperly claimed.
How should providers handle a lapse in a plan of care?
Providers should update and rectify plans of care promptly when there’s a delay in treatment continuity. Documentation must justify the necessity of ongoing treatment, especially after a denied claim.
What is “unbundling” and why is it a concern in Medicare billing?
Unbundling is the practice of billing individual components of a service separately instead of as a package. Medicare considers this improper if the separate services aren’t allowed under their guidelines, and it may result in repayment demands or penalties.
