What is a Medicare post payment review?

Alternatively, a Medicare postpayment review is the review of claims after they are paid. They can result in a change of payment, meaning that the provider may owe Medicare or a health plan money — or vice versa. Postpayment review strategies include data analysis and medical review.

How far back can Medicare audit?

three years
Medicare RACs perform audit and recovery activities on a postpayment basis, and claims are reviewable up to three years from the date the claim was filed.

What are the two types of Medicare audits?

Types of Medicare Audits

  • Recovery Audit Contractor (RAC) Audits.
  • The Certified Error Rate Testing (CERT) Audits.
  • Probe Audits.
  • Check the address on the letter and ensure that it is the address of your practice.
  • Make contact with the auditors.
  • Keep copies of all transmitted documents to the auditors.

What triggers a Medicare audit?

What Triggers a Medicare Audit? A key factor that often triggers an audit is claiming reimbursement for a higher than usual frequency of services over a period of time compared to other health professionals who provide similar services.

What is post-payment audit?

Post-Payment Audit Home The purpose of Post-Payment Audit is to confirm the eligibility and integrity of the provider´s EHR Incentive Payment information submitted within the attestation portal.

What triggers a RAC audit?

RAC audits are not one-time or intermittent reviews and can be triggered by anything from an innocent documentation error to outright fraud. They are part of a systematic and concurrent operating process that ensures compliance with Medicare’s clinical payment criteria, documentation and billing requirements.

What happens during a Medicare audit?

According to the CMS website, CERT audits are conducted annually using “a statistically valid random sample of claims.” Auditors review the selected claims to determine whether they “were paid properly under Medicare coverage, coding, and billing rules.”

What is the lookback period for overpayments?

Six Years
Lookback Period Shortened to Six Years In the A and B Final Rule, CMS pulls back from its original proposal stating that overpayments must be reported and returned only if a person identifies the overpayment within six years of the date that the overpayment was received.

What happens in a Medicare audit?

What is the purpose of Medicare audits?

The Medicare Fee for Service (FFS) Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of health care services provided to Medicare beneficiaries, and the identification of underpayments to providers so that …

What is Post audit and pre audit?

The Audit Process can be divided into three distinct phases each of which consist of an interrelated set of procedures necessary to conduct an effective audit: Pre-audit Phase (or planning phase) Audit Phase (or auditing phase) Post-audit Phase (or reporting phase)