“Finally Friday!” How Your Claims May Be Inviting Audits

FRIDAY March 6, 2015:

Is Your Barn Door Open?
How your claims may be inviting Audits

Auditors look for patterns, why don’t you?

Watch for the Handouts

Pattern recognition is used in fingerprinting. Various patterns are also used by auditors to find "alleged offenders" among provider claims databases - and more and more databases are available for that purpose, today. Do YOU look for your own patterns?

Pattern recognition is used in fingerprinting. Various patterns are also used by chart auditors to find “alleged offenders” among provider claims databases – and more and more databases are available for that purpose, today. Do YOU look for your own patterns?

Nationwide databases are now publicly available providing average charges by hospitals. CMS publishes recent data of the average charges and payments for Medicare claims, by provider, including state and national averages.

Recent legislation now requires hospitals to post their top DRGs, top procedures, top payments, etc., all in the name of “transparency,” thus allowing both the public and the payors to easily apply data analytics – something payors are very good at doing. Virtually all payors are known to be looking for patterns to find “suspect” behavior. The real tragedy is that some pretty simple proactive behavior could be employed by a provider to find the same pattern, either before or after denials occur.

Bill Malm, ND RN CMAS CRCR

Bill Malm, ND RN CMAS CRCR

Join us on the show to learn from our audit expert, Bill Malm, a Senior Manager at Craneware, practicing clinician and Adjunct Professor at New York University:

  • Common patterns that interest auditors;
  • Common examples that generate denials;
  • and recent moves by Payors away from Fee-For-Service plans (and what that means for providers).

So the question is… do YOU look for patterns? If not, why not? CAN you look for patterns? And again, if not, why not?

Be sure to listen in as we discuss how you can detect patterns, both reflexively and proactively.

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Handouts for This Week's Show

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REPLAY of This Week's Show

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We Appreciate Our Sponsors for this show:

 Craneware  |  The Health Law Partners | Recovery Analytics

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