Law firms have been known to enlist the help of a third-party when dealing with healthcare fraud cases. This is because in addition to investigating the allegations against one party, there is a myriad of additional pre-litigation considerations. In multi-faceted cases in which health plan overpayments are being pursued within the judicial system an audit is almost always an absolute necessity. Audits require claims selections, the acquisition of medical records, audits, and reports. Each of these components require a meticulous approach and definitive guidelines, many of which revolve around fraud, waste, and abuse (FWA).

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The concept of fraud, waste, and abuse is a popular talking point in the realm of healthcare compliance. While it’s handy acronym suggests uniformity among the three terms, their definitions are incredibly important to consider when entering a situation requiring litigation and/or arbitration. In terms of pre-litigation efforts, the distinction between fraud and abuse is imperative to procedure.

Humana defines the two as:

Fraud is generally defined as knowingly and willfully executing, or attempting to execute, a scheme or artifice to defraud any health care benefit program or to obtain (by means of false or fraudulent pretenses representations, or promises) any of the money or property owned by, or under the custody or control of, any health care benefit program.

Abuse: Payment for items or services when there is no legal entitlement to that payment and the individual or entity has not knowingly and/or intentionally misrepresented facts to obtain payment.

These explanations matter because to an audit firm or an investigative team, the fraud and abuse designations mean different things in terms of claims selection methods, look back periods, and extrapolation. Will patient records for an entire year be requested, or simply a few dates of service? Will the frequency of modifier application be observed? Will the claims selected be at random from a pool of provided patients? The answers to these questions may change depending on whether investigators are looking for evidence of fraud or abuse.

Now that you’ve figured out audit methods there are a few more items to consider and/or arrange:

Location of Audit

  • Auditors should be conducted the audits at a provider’s site unless otherwise agreed. This is done to prevent unnecessary photocopying of MRs, ensure confidentiality, and to efficiently handle questions that might arise on the provider end.
  • If the audit cannot be conducted on site, it is detrimental to implement uniformity among submission guidelines, as well as billing procedures for the audits themselves. These billing procedures will often encompass fees to cover the cost of transportation, photocopying, and the additional supplies needed to carry out the off-site audit.

Request for Audit

  • It is standard for payers to request audit documentation from their providers at least 21 days before the audit will officially begin.
  • Providers are expected to respond to audit requests within one month. The provider and audit firm will then coordinate a date and time no later than 90 days after the request.
  • Providers who are unable to accommodate the audit requests in accordance to audit guidelines should explain in detail why the request cannot be met in the period requested.

Auditor Qualifications

  • Identifying the kind of auditor best suited for your specialized audit project can be overwhelming when you consider the sheer volume of medical coding and auditing certifications that exist. Utilizing a well-balanced team of auditors and claims examiners is one of the most important things you can do to ensure your results are high quality. These certifications may be indicative of an audit team member and subject matter expert: Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), Certified Fraud Examiner (CFE), Accredited Health Care Fraud Investigator (AHFI), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), and many more.

You’ve got your team together – what’s next? Check out our follow up post on citation guidebooks, regulations, claims reviews, quality assurance, and preliminary audit results.