Be a process owner of a project or CEO of a company, everyone gets sleepless nights with a mere thought of audits. The basic purpose of any audit is to check if everything within the process is maintained properly or not.
Ambulatory Surgical Center (ASC) is a healthcare facility that provides medically necessary surgical services to a patient in the outpatient setting who have already seen a health care provider. ASC billing services include billing of cases created for procedures performed by physicians, suppliers and other non-institutional suppliers for both outpatient and inpatient administrations. For billing, certified medical coders review a patient’s medical record and assign codes in the Healthcare Common Procedural Coding System (HCPCS) to describe the services performed. These codes are then assembled by professional medical billers on a CMS-1500 claim form as established by the Health Insurance Portability and Accountability Act of 1997 (HIPAA).
However, ASC’s billing services are not always devoid of errors which can originate from different reasons like – incorrect codes, lack of monitoring, inconsistency in the billing methods, not following professional standards, at times breaking out services and billing as separate procedures when they need to be included.
To check these mistakes and keep the billing process intact, the audit is essential wherein the auditors will check certain factors like coding, charge posting, use of modifiers, payment posting and collections. But, in general, to avoid Medicare audits, ASC needs to have detailed and accurate billing documentation in place. Their system needs to invite more well-trained medical coding professionals plus they need to conduct internal audits on an annual basis so as to overcome the inhibition behind audits. They also need to review the electric medical record system so that there is consistency in medical coding and billing processes.
To give a detailed picture on how Medicare audits can be avoided totally, few important measures need to be followed by ASC like
- To avoid false claims, thorough documentation needs to be done before sending the patient to the doctor
- Time of surgery needs to be noted and billing needs to be done accurately in special cases as well
- Consultations of patients are part of service and are not to be charged separately
- Concurrency is another important aspect of the billing procedure and to be applied for each patient whose case it is being billed under
Audits are necessary and might not be avoidable all the time. Hence, it is critical for the surgery centers to keep up with Medicare coding rules and guidelines, keep a track of denied claims and monitor audit focus issues, which are published regularly by the contractors. They also need to monitor previous audit results and work on avoiding the issue in the future.