Medicare and Medicaid Audits

Centre for Medicaid and Medicare Services (CMS) has been intensively working against frauds, waste, and abuse. There is a stringent review of services billed and the general billing practices of the healthcare unit. As estimated by the CMS, significant sums of money are misspent and improper payments are done every year.

There are following types of Audits and you may require professional assistance to ensure you do not falter in any procedure. Any non-compliance may lead you to complex problems and affect your business continuity.

Medicare and Medicaid Audits

The seven common audits are:

  • Medicare Recovery Audit Contractors (RACs)
  • Medicaid RACs
  • Medicaid Integrity Contractors (MICs)
  • Zone Program Integrity Contractors (ZPICs)
  • State Medicaid Fraud Control Units (MFCUs)
  • Comprehensive Error Rate Testing (CERT)
  • Payment Error Rate Measurement (PERM)

Knack Global is an expert in the healthcare industry. We have extensive and intensive experience in every system of the healthcare administrative and billing cycles. Medicare Audit is one of our expertise and we execute with strict confidentiality.

Although, various Medicare contractors offer auditing of records, claims, and payments. They may use different methodologies but must abide by the CMS guidelines.

Medical Review Standards

Medicare contractors need to audit according to the guidelines for review and provider reasons of denial

Pre-payment review

This is the initial step for assessing and determining the current claims. The claim is processed once it is determined that the services were reasonable.

Post-payment review

It is revised determination and may require the provider to return the amount for the services that were viewed as unnecessary.

Automatic or non-complex Reviews

They may occur without a clinical review of medical documentation as submitted by the provider.

Complex reviews

This is a detailed process and involves requesting, receiving and review of documents related to the claim. Other healthcare professionals may be involved in consultation and review.

Audit Review %

100

Claims Reviewed every year

100,000

Threefold Increase in successful Appeals

3x

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