Auditors Are Ramping Up Operations

There are no indications that audits of healthcare entities by government payers are slowing down – if anything, the ramping up of audit operations that was hinted at a short while ago has indeed materialized. Commercial payers are moving just as aggressively, based on the cases on which I’m engaged. Since my last Monday Monitors article, the following are new cases:

During the week of Oct. 7, a Florida client received 14 targeted probe-and-educate (TPE) letters for their providers;

– Fidelis New York received a demand for $868,000;
– Blue Cross Georgia received a demand for $365,000;
– Blue Cross Texas received a demand for $143,000;
– A two-count grand jury indictment for healthcare fraud scheme or artifice in Miami was handed down, resulting in an asset seizure of $864,000;
– A Centers for Medicare & Medicaid Services (CMS) referral to the U.S. Department of Treasury was made for three outstanding audit demands from FCSO, amounting to $64,000;
– A six-count grand jury indictment for healthcare fraud scheme or artifice in Michigan was handed down, with a demand of $2 million; and
– Three separate laboratories in Georgia, Tennessee, and Indiana were hit for UTD panels, resulting in demands ranging from $72,000 to over $1 million.

My specific focus is on strategic audit defense, which means my role centers on audit results and the language used by payers and government investigative agencies. The key to audit survival and/or mitigation of damages lies in your ability to remain vigilant regarding compliance with coding and documentation requirements, and ensuring your providers can defend their clinical judgement and the medical necessity of the services they render and/or order!

Source: Auditors Are Ramping Up Operations / RACmonitor

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