Discussion Reply- Response 1-2 paragraphs with 1-2 references

Zana

The medical industry today is highly regulated and requires health care providers to be up to par with countless government and federal policies and regulations. An example of one of those policies is The Recovery Audit Program that Medicare Fee for Service providers are exposed to. The Centers for Medicare and Medicaid Services (CMS) is the US agency that is responsible for the regulation Medicare fraud, abuse, and misuse. The purpose of the Recovery Program is to identify improper payments made on claims of health services provided to Medicare and Medicare Beneficiaries (Cammarata, 2017). As a healthcare administrator in a hospital environment, there would be various steps I would take to ensure that my organization in in compliance with the standards and specifications of this policy.

It is critical that health providers and coordinators practice accurate documentation and recordings of patient information. This includes ensuring that an organization’s medical and billing department correctly enters service codes, providers submit documentation that supports patient ordered services, and identify weather or not services meet Medicare’s coverage and medical necessity criteria. Proper documentation is crucial for a health organization facing an audit since the Government Accountability Office’s (GAO) report of 2017 confirmed that nearly $78 billion dollars of government-wide improper payments are a result of insufficient documentation and inability to authenticate eligibility (Cammara, 2017).

To further prepare for an audit, I would ensure that various departments within the healthcare organization work together to ensure knowledge and compliance of each type of coverage policy. This includes keeping a detailed record of patient records from physicians and documentation of required treatments and why they were considered necessary. Additionally, the healthcare organization should remain up to date on Medicare’s latest policies and guidelines. Employees and providers working in the billing department should also be very careful in reviewing all claims before they are submitted for payment. I would also work with other providers of managerial status to develop written policies, processes, and a checklist to prepare the healthcare organization for an audit. To further assess preparedness, I would implement internal random audits as a preventative measure to prepare for recovery audit contractors.

Once an audit takes place, it is important as an administrator to review the paperwork that was received from Medicare to observe what has been requested such as medical records and documentation. Medical organizations under audit have 45 days to respond to the paperwork and up to 14 days of requested extension (Cammara, 2017). Once records are found, they should be carefully labelled in a format that is easy to review such as Exhibit A, Exhibit B, etc. (Cammara, 2017). Files should be mailed in accordance with Medicare standards and my healthcare organization should use a professional tracking method to ensure that the files were properly received. Once the audit has been reviewed by Medicare, healthcare organizations are granted by levels of appeal; payments are required after the second appeal (Cammara, 2017).

Zana

Reference

Cammarata, E. (August 10, 2017). A How to Guide Navigating RAC Audits for Medical Practices. https://www.cbsmedicalbilling.com/a-how-to-guide-for-navigating-rac-audits-for-medical-practices/