How to Juggle Medicare and Medicaid Compliance in a Fluid Regulatory Landscape

Do you treat patients insured by Medicaid or Medicare at your hospital? While participation is voluntary for for-profit healthcare systems, accepting Medicaid and Medicare patients is a condition of federal tax exemption for non-profits. Currently, Medicare and Medicaid account for more than 60 percent of care provided by hospitals making it nearly impossible for healthcare systems to forgo these programs.

So, if the stark reality is that you must participate, compliance becomes an issue. And it’s complex. Especially for hospitals that have multiple outpatient locations and inpatient campuses. Under Medicare provider-based rules, it’s not possible to certify just part of the system. When you consider there’s nearly a 500-page certification process, it’s clear that it’s crucial to have effective compliance tracking.

An effective compliance program is multi-faceted and includes monitoring and auditing, legal reviews of procedures and contracts, reporting mechanisms as well as training for employees. Healthcare systems are multi-faceted too with labs, pharmacies, rehabilitation centers, clinics, surgery centers and more. Keeping on top of compliance not only to effectively report but to identify and then prevent misconduct before it balloons into a much bigger problem is anything but easy.

The Centers for Medicare & Medicaid Services has attempted to streamline information into quarterly updates for providers, suppliers and the public. While this helps curate the information and updates to regulations, management and oversight of compliance and putting these regs into practice represents an enormous task for each healthcare system. The distance between knowing and doing can be vast when providers are juggling regulations alongside providing quality patient care. Maintaining oversight of not just the Medicare and Medicaid federal regulations, but compliance with other state and local regulations is required.

The regulatory landscape continues to be muddled with additional requirements to safeguard privacy and to fight fraud and abuse today. Since governing bodies are vigilant about fighting fraud, your compliance process needs to be tight or you’ll risk criminal charges, fines and even the possibility of losing licenses. Every state has its own Medicaid Fraud Control Unit (MFCU), typically as part of the State Attorney General’s office. When your compliance tracking system is thorough, the auditing process and working with your MFCU becomes simpler.

Streamline Compliance Tracking

If your hospital is juggling Medicare and Medicaid payment compliance along with all the other mandates and reporting requirements, it can easily get overwhelming. But, it doesn’t have to be that way. Solutions such as youCompli’s compliance system monitors and translates Medicare and Medicaid regulations for easier understanding. Then, it helps you track and oversee your hospital’s compliance.

If you’re ready to take the headache out of Medicare and Medicaid compliance, it’s time to see what a compliance management system can do for you. Schedule a call today where you can see how our risk management software can support your healthcare system’s compliance program.

5 Payer Audit Errors Every Hospital Must Avoid

5 payer audit errors

Revised September 2022

Most healthcare providers, from large hospitals to solo practitioners, experience an external audit at some point. The scrutiny can unveil errors and violations, which can lead to hefty penalties. 

The key to surviving an external audit, with the least amount of frustration, is to avoid these five common mistakes. 

1. Late Responses

Your deadline to submit relevant documentation begins upon receiving that external audit request. 

External audits may be requested by a commercial health insurance payer, or government agencies such as the Centers for Medicare and Medicaid Services (CMS) or Office for Civil Rights (OCR). While the origin of the audit request doesn’t matter, a timely response is essential. 

Take all deadlines seriously. If an extension is needed, ask for one, immediately. Missing deadlines can result in hefty fines and penalties. 

2. The Wrong Documentation

A common trigger for payer audits is improper or lack of necessary documentation.  As a healthcare practitioner, you must prove the medical necessity of each test or procedure used to diagnose and treat your patients. 

Here’s the tricky part. Sometimes payers and providers disagree on what tests or procedures are medically necessary.  Additionally, medically necessary guidelines change frequently. CMS provides local coverage determinations (LCDs) and national coverage determinations (NCDs) to help with your documentation. Be sure you are aware of changes to these coverage determinations.  

The best way to mitigate this problem is to educate your staff on what services the payer considers medically necessary, and what documentation is required to establish medical necessity. 

 Additionally, clearly document the need for a particular procedure to treat or diagnose a patient. Finally, when required, ensure that authorization is received from the payer before rendering services. 

3. Billing the Wrong Codes

Incorrect billing and coding practices can raise suspicion of fraud, failed claims, or delayed reimbursement, and — you guessed it — external payer audits. Providers and patients overpay a whopping $68 billion annually due to incorrect billing. 

 Coding systems developed by the American Medical Association and the Centers for Medicare and Medicaid are designed to streamline the billing process. Every medical procedure and service from ambulance rides to chemotherapy drugs to doctor visits are contained within coding systems such as the ICD-10, CPT, and HCPCS. 

Studies show 80 percent of medical bills in the U.S. contain errors. This percentage can decrease by ensuring appropriate staff stay current with billing and coding updates and communicate those changes to the right clinical and administrative staff to avoid old and outdated codes. 

4. No Self-Audit

One way to prepare for payer audits is to perform regular self-audits within your facility.  Internal audits are great for identifying and eliminating weak spots that can potentially lead to headaches down the road, like rejected claims and costly compliance failures. 

 One drawback is the strain on precious resources like time and personnel. You can get around this problem by hiring a third-party audit service. Make sure you have HIPAA-compliant Business Associate Agreements (BAA) so that you’re allowed to share your patient health information with third parties providing auditing services.  

 Another option is to use software provides 24/7 access to survey compliance data. Ideally, this software will provide automatic tracking of all documentation and decisions involved in the process of running your organization. 

 This ensures that compliance professionals can get immediate reporting on how well their team is doing, conducting audits more efficiently and effectively. It’s a time and cost-effective solution to hiring an outside third-party provider. 

5. No Legal Help

Having a healthcare attorney in your corner can mean the difference between a smooth audit experience and an audit nightmare. 

Here’s how a healthcare legal team can benefit your health practice: 

  • Work intimately with your staff to analyze any risky billing procedures. 
  • Challenge any demands from payers for overpayment. 
  • Challenge any allegations of fraudulent billing practices. 
  • Push back on any denied claims and the overuse of service claims. 

 Again, software is a useful tool to support your attorney’s work. A system that stores all compliance information, including payment practices, and has search capability will provide your legal team with the information they need to fight payer audit discrepancies when the time arrives. 

 External payer audits don’t have to be a nightmare. By being adequately prepared and vigilant, your next audit experience can be more streamlined and less stress-inducing. 

Learn More About YouCompli

The best way to prepare for a payer audit is to carefully manage changes to regulatory changes and coverage determinations. YouCompli can help you establish a scalable, repeatable process so you don’t miss a relevant change and you can equip your clinical colleagues to respond to the change. Then, when the audit does happen, you’ll have an easy way to demonstrate your work to comply with the requirements. Find out more. 

Jerry Shafran is the founder and CEO of YouCompli. He is a serial entrepreneur who builds on a solid foundation of information technology and network solutions. Jerry launches, manages, and sells software and content solutions that simplify complex work. His innovations enable professionals to focus on their core business priorities.

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