Government payors and commercial insurance companies rely on pre- and post-payment medical record and billing audits to determine if provider services were medically necessary, accurately billed, and appropriately paid. Over the past few years, Medicare significantly increased the types and numbers of audits and outsourced many the record reviews to private companies. With so many of these private companies conducting audits on behalf of the Medicare program, it is not a matter of if a provider will be audited, it is a matter of when.  Moreover, many of the contracts with private auditing entities incentivize denials by tying compensation to the amount of money recovered.   Negative audit results can lead to significant penalties, including repayment, financial penalties, de participation, and even prison in the worst cases. 

Commercial insurance companies also rely on medical record and billing reviews of participating providers to ensure that the services meet all utilization, medical necessity, and payor policies.

There are steps providers can take to minimize the chances of a negative audit result.  Join our expert speaker Vicki Myckowiak for an intensely practical discussion on the best way to handle payor audits from the receipt of the record request through submission of the records and learn about best practices for handling appeals of adverse findings.