Questions

The inquiries that these agencies and contractors can conduct include a wide variety of questions that include, but are not limited to, the following:

Was the bill that was submitted and paid accurate?
Was the patient accurately diagnosed?
Was the care or item billed for actually provided to the patient?
Was the care or item billed for medically necessary and appropriate?
Was the care or item billed for eligible for Medicare or Medicaid reimbursement?
Was the need for the care or item properly documented in the patient's medical record?
Were prescription drugs or medical equipment properly prescribed by a physician or other authorized medical professionals?
Was the care or item billed for of acceptable quality, and provided on a timely basis?
Were the medical services provided by appropriate professionals with current licenses who are in good standing with the Medicare and Medicaid programs?
Was other health benefit coverage exhausted before Medicaid was billed?
Was the patient billed for any applicable co-insurance or deductible?
Were the institutional cost reports that were filed by the provider accurate in all respects?
Were any of the provider's business arrangements, patient referrals, etc. violative of any fraud and abuse statutes?
Have any medical, billing or business records been altered?

Approach

An audit or investigation can be commenced in a number of ways. It can be a simple letter from a Medicare carrier or intermediary requesting information and a copy of portions of a medical record so that a bill for patient services can be reviewed. It can be one or two investigators who show up at a facility, flash their badges (they love to do that) and ask to see records or to interview employees immediately. Or, it can be the arrival of a team of auditors at a facility for a wholesale review of the records of Medicare or Medicaid patients, or the facility's contracts, business arrangements, cost reports, and other records.

Instant Insights /

Medicare and Medicaid audits and investigations: Digging into the details

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