Medicare Audits – “reasonable and necessary”
With the Federal government contracting and double checking its spending, health care practitioners are under the microscope for their billing practices. If you have been contacted for a Medicare audit or are currently undergoing a medicare audit, then, there are a few things you want to know.
First off, what are they looking for?
Billing and coding over what the actual services performed is the crux of a medicare audit.
Providers that could be audited are hospitals, physical therapists, nursing homes, and private physician practices – any entity that bills medicare.
In 2017, the USDOJ with joint efforts with the FBI uncover fraud worth $1.3 billion, where medical practitioners were over billing their patients. At times, some medical practitioners were actually driving around trying to find homeless individuals and paid them cash to use their cards to bill medicare.
Physical Therapists are commonly targeted for billing related to the KX modifier. Use of this is to signal an automatic exception to the therapy cap on the basis of normally accepted necessity. This is also seen where providers are billing an unusually higher number of codes for each visit by their patient. Things as simple as missing practitioner signatures, or using a rubber stamp or electronic signature may indicate the absence of the practitioner that would actually call for the level of billing that was actually billed.
Practitioners should remember to rectify a plan of care when time has lapsed since the onset of care. There needs to be sufficient documentation as to post-denial of claims.
To revisit the issue of signatures, billing rates are different when services are provided by each specific type of provider – physician versus nurse. The same applies to billing separately or “unbundling” services such as dressing and warm packs.
Medicare Audit Atlanta