Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.
- Presentation
Audits and Denials - Tips and Tricks for Success
Description
In this lecture on audits and denials, key distinctions between audits (post-payment reviews) and denials (pre-payment reviews) were discussed, highlighting the challenges posed by increasing reliance on AI in claims review, exemplified by lawsuits against Cigna and UnitedHealthcare. The speaker introduced different types of audits, such as commercial payer audits, Medicare audits, and unified program integrity audits (UPIC), emphasizing their varying levels of concern and processes. Specific focus was given to issues like the importance of documentation accuracy, the correct usage of modifiers (specifically modifier 25), and the significant impact of recent changes in policies from payers like Aetna. Common causes of claim denials such as inaccurate information and coding errors were highlighted. The speaker stressed the significance of maintaining thorough and precise documentation, being vigilant about coding compliance, and the necessity of prompt responses to audit notifications. A structured audit plan, regular internal reviews, and potential corrective measures were advocated to mitigate risks. Lastly, an in-depth overview of the appeals process for denied claims was provided, encouraging practices to engage proactively with audits and ensure compliance with evolving payer demands.
View moreConclusions
- Audits and denials in healthcare are increasingly prevalent and often challenging for providers.
- Different audit types vary in their focus, including commercial payer audits and federal government audits.
- The introduction of AI in claims processing raises concerns about accuracy and the potential for wrongful denials.
- Missing documentation is a significant contributor to claim denials, accounting for about 40% of cases.
- It is crucial for providers to maintain accurate and thorough documentation to reduce the risk of claims being denied.
- Modifiers, especially Modifier 25, are commonly misused and contribute to denials, emphasizing the need for proper education on coding.
- The appeals process for audits and denials is robust, allowing providers avenues to contest unfavorable determinations.
- Self-disclosure of potential fraud may lead to less severe penalties compared to audits that uncover issues post-factum.
- Staying up-to-date with billing compliance, coding standards, and documentation practices is pivotal for reducing audit risk.
- Auditor scrutiny is increasing, especially regarding high-level E/M services and medical necessity definitions.
- Rucker, P., Miller, M., & Armstrong, D. (2023). How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them. ProPublica.
- Napolitano, E. (2023). Cigna Claim Reference. CBS News MoneyWatch.