The Future of CMS Audits

Oct 24, 2017 | Best Practices, Business Tips, Healthcare Industry, Knowledge Center

In 2014, The Centers for Medicare & Medicaid Services began a program called ‘Probe and Educate’ that paired a review of a sample of claims with education to help decrease errors in the claims submission process. Currently, Medicare Administrative Contractors (MACs) flag and challenge claims at random which has led to a high backlog in appeals.

Earlier this year, there were more than 667,000 pending appeals, and CMS projects the number of pending appeals will rise 3% by the end of 2017. That number could eventually rise 46% by the end of 2021 to just over 1 million claims.

CMS recently unveiled their plans to implement a new audit strategy, ‘Targeted Probe and Educate,’ in which MACs will choose claims for items and services that bear the highest financial risk to the Medicare trust fund and/or those with a high national error rate. This program began as a pilot in one MAC jurisdiction in June 2016 and expanded to three more in July 2017. By the end of this year, all MAC jurisdictions will be included.

“This takes the pressure off folks that are doing everything right,” said Dr. Ronald Hirsch, a vice president at R1 Physician Advisory Services. This new approach represents a considerable change in the status quo in that many providers will no longer face audits.

Are YOU doing everything right? This may be a significant burden off your shoulders, but in the meantime, make sure your organization is prepared for an audit by following these guidelines:

1. Always be prepared for an audit.

Take it seriously and make sure you are ready by participating in mock audits. There are practiced experts available to support your efforts to help audits run smoothly and efficiently.

2. Have a defined audit management process — and follow it.

Audit timelines are short, so have a solid audit management process to keep deliverables on-track. Expect issues to arise, and have processes in place to identify and resolve them as quickly as possible.

3. Strive for high-quality, sound operational compliance.

Compliance is essential to successful health plan operations and audit outcomes. Thorough compliance not only sets the bar for smoother audits, it contributes to excellence, higher ratings and fewer errors, corrective actions, and financial penalties.