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Billing Audits and Compliance

June 19, 2014

Damaris Medina gave a webinar to members of the Urgent Care Association of America on “Billing Audits and Compliance.”

The current economic climate has motivated an increase in attempts by government agencies and private payers to investigate coding and supporting documentation. The escalating pressure on both government and commercial payers to decrease costs has resulted in an increase in audit activity on payments to physicians and Urgent Care Centers to recoup costs. Based on its own statistics, in 2012 the government allocated at least $600 million towards recovering payments made to Medicare Fee-For-Service contractors. That same year, the government recovered more than $4 billion from a number of sources related to audits, investigations, and civil and criminal penalties. Based on the phenomenal return on investment, the trend of increased government audit activity is likely to continue. Commercial payers are following the government’s lead. Commercial payers commonly focus on particular code groups or particular issues. The identification of the higher levels of E/M services (specifically CPT codes 99214 and 99215) by the government as an issue area is expected to prompt commercial payers to increase their scrutiny of these codes. Therefore, urgent care centers must become “audit-ready”.

At the conclusion of this session, attendees:

  1. Knew the current trends in commercial and government payer audits;
  2. Understood the different auditing sources and what their target areas are;
  3. Knew what to do to prepare for audits from both commercial and government payers;
  4. Understood compliance programs and how to implement them successfully;
  5. Learned how to respond to different types of audits; and
  6. Had concrete tips on how to prepare for and respond to an audit.

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