Can We Expect Medicare Audits to Be Friendlier in 2018?

Wed, Feb 28, 2018 --


No matter how careful you are, Medicare audits happen — and if the thought of an audit is keeping you awake at night, there could be some good news coming your way! This year, the government is supposedly taking a more lenient and educative approach to rectifying Medicare billing errors.

Background: For some time now, the American Medical Association (AMA) and CMS have been meeting regularly to talk about MACs and RACs.

According to the AMA, most physicians are honest and make a true attempt to comply with Medicare program requirements. But the government’s attempts to address waste, fraud, and abuse issues add unwanted burden on providers. The AMA says its goal is to ensure that the federal government’s program integrity policies are justifiable.

AMA’s advocacy for improvements (both previous and recent) include:

  • RACs need to have medical directors, certified coders, and an online presence where physicians can check audit status
  • RAC contingency fees should be paid back if an appeal is lost
  • A RAC must send audit results to providers prior to sending results to CMS
  • Physicians have 30 days to request a discussion about the results with the RAC
  • Physicians can also submit additional documentation/details to explain how their choices comply with Medicare rules
  • Physicians can also ask to discuss a file with the RAC’s medical director, the physician who checked the file, and a RAC physician in their specialty to resolve issues without a formal appeal.

Through these prior discussions, CMS may be able to find patterns in RAC issues, which in turn will help resolve issues in the RAC process, the AMA states.

CMS Heeds AMA’s Requests:

Several of the requests in AMA’s letters to CMS will likely be granted, including these:

  • Clearly define contractors’ function/scope of authority
  • Introduce an online portal for consolidating details on program integrity efforts
  • Step up physician education efforts on ways to avoid common coding/billing mistakes
  • Coordinate with healthcare practices to look at areas for improvement
  • Use predictive analytics to zero in on claims most likely to yield improper payments
  • Swap to corrective action plans instead of fines.

Good news: CMS has already implemented some of these recommendations, the AMA states. The AMA has urged CMS to focus on those physicians who have a tendency to commit fraud or abuse. And the Targeted Probe and Educate (TPE) program is a key step in this direction.

Stay alert for new details as they emerge from CMS and the MACs.

What About You?

What’s your take on this new development? Will it reduce your audit burdens? Let us know.


Deborah concentrates on coding and compliance for radiology and cardiology, including the tricky world of interventional procedures, as well as oncology and hematology. Since joining The Coding Institute in 2004, she’s also covered the ins and outs of coding for orthopedics, audiology, skilled nursing facilities (SNFs), and more.

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