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Physician groups face the risk of losing hard-earned revenue through payer audits. While claims are initially paid in “good faith” based on claim submissions, subsequent carrier audits may reveal that the billed services lack appropriate supporting medical record documentation. This can result in a significant loss of revenue, administrative time burden, and future prepayment reviews. The issue of improper payments is far from insignificant. In 2023, the Department of Health and Human Services reported a staggering $100 billion in improper payments within the Medicare and Medicaid programs.

During this session, we will explore areas frequently audited by carriers and often inaccurately documented by physicians. These areas include Evaluation and Management (“E&M”) codes, telehealth services, and medical necessity. This presentation will demonstrate how to utilize the Centers for Medicare and Medicaid Services’ Improper Payment Data and insights from the Office of Inspector General’s Work Plan to assess current audit targets and identify effective preventive measures. Also covered will be strategies for effectively communicating documentation requirements to physicians and mitigating your organization’s risk of audit recoupments.

Learning Objectives/Agenda

• Understand how the medical claims adjudication process can lead to insurance carrier audits
• Learn how to utilize the Centers for Medicare & Medicaid Services' improper payment data to target and address compliance concerns
• Examine the underlying causes of improper payments for medical claims
• Review coding, billing, and regulatory updates relevant to coding compliance
• Identify opportunities for process enhancements and education to support revenue growth and mitigate the risk of revenue loss due to carrier audits

Why is this topic important?

The current economic landscape has narrowed healthcare operating margins, emphasizing the need for complete revenue capture and retention. When addressing revenue retention, revenue cycle teams often focus on expediting claim submissions and effectively handling denials. Equally important is ensuring that revenue received is not lost to future carrier audits.

Medicare’s Fee-for-Service program alone accounted for an estimated $31 billion of improper payments, constituting over 7% of total payments. Considering the administrative costs associated with recoupment, these already slim operating margins face further potential decline.

Who would benefit from this topic?

• Medical Billers
• Medical Coders
• Practice Adminiatrators
• Physicians and Non-physician Practitioners
• Compliance Officers
• Auditors

What is the presenter's background/expertise on this topic?

Nancy Clark is a skilled healthcare consultant specializing in optimizing revenue cycle processes. She has extensive experience in medical coding, education, and auditing. Nancy is highly regarded for her ability to conduct coding audits and incorporate the results into customized education delivery for physicians, coding professionals, and revenue cycle staff. In addition, she supports providers during insurance carrier coding audits and serves as an expert witness. Nancy has worked in diverse specialties and settings, providing successful revenue cycle management for large physician groups and hospitals.

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