In recent Medicare Audits, over 80% of glucose testing supplies and nearly 70% of nebulizer and nebulizer solutions claims were denied. This resulted in BILLIONS of dollars being recouped from Medicare suppliers and providers.
Purpose of Medicare Audits & What to Expect
Before you start preparing for a Medicare audit, it’s important to understand its primary rationale so you clearly know what to expect. When an auditor pays you a visit, keep in mind that they have a two-fold purpose: checking that your practice is free of non-compliance and fraud. In short are you acting in good faith and in compliance?
Audits are becoming fairly common, so it’d be best to always be prepared for a visit from a Medicare Auditor. In fact audits are increasing to the point that Medicare has collaborated with third-parties for conducting audit visits to keep pace with the ever increasing demands, which have only intensified, given the expanding number of healthcare providers and services.
Documentation is Important
The first step in preparing your pharmacy for an audit is making sure you have the necessary documentation and that it is in compliance with the rules set forth by the Center for Medicare Services (CMS). Being equipped with the right documentation to minimize your probability of claim denials is half the battle won.
For instance, does your detailed written order include the physician’s name, signature, and date apart from the other elements including patient’s name, order date and start date (if different), and a detailed description of the item? A DWO is just one of the several documents and it may be hard to store and organize your documents without the right software.
Consider using one of the various tools available to streamline your documentation gathering and storage needs. The ideal solution would not only ensure compliance but make the process extremely easy and convenient. However, that alone may not guarantee a favorable audit result.
Here are some other crucial measures you can take to increase your probability of successfully passing an audit:
As a Pharmacy Owner, how can you be prepared if an Auditor comes to your door?
When working with clients, I let them know there are several things that they can do in their pharmacy to help prevent the clawback of hard earned revenue.
- Be sure you are in Compliance with all 30 Medicare Supplier Standards, whether you are accredited or not.
- Understand your DME-MAC’s LCDs (Local Coverage Determinations)
- Have a checklist available of all information that is required in a patient’s file.
- Perform internal audits and quality assurance checks to ensure that all of your patient files have the proper information included in them.
- Have an open relationship with dispensing physicians so you can easily obtain needed information before sending your claims to Medicare.
- Keep an eye on your mail, most audits will be a request for documentation sent to you by a Medicare Contractor and give typically 30 days to respond. If you don’t reply, you will have lost your monies.
- MOST IMPORTANTLY — keep your staff trained and up to date on all requirements!
Make these practices part of your daily routine and you will be ready when that Medicare Auditor comes knocking.