September 8, 2022
Increasing audits create need for full compliance assessment
Payment-Related Audits Infinity

Increasing audits create need for full compliance assessment

Medicare and Medicaid program integrity and payment-related audits are on the increase with Medicare contractors searching out providers who took advantage of the pandemic to step outside the rules, cheat the system, or pad their pockets.

And it’s not just the unscrupulous who are feeling Medicare’s renewed zeal for uncovering fraud and abuse.

Almost all providers will feel the impact as audits increase, investigations toughen, and the Centers for Medicare and Medicaid Services (CMS) shifts into scrutiny mode after some degree of leniency during the pandemic years, according to the compliance experts at SimiTree, INFINITY’s strategic partner.

They attribute rising numbers of payment-related audits over recent months to a directive from the Office of Inspector General (OIG), the federal agency in charge of investigating Medicare fraud and abuse.

“In its most recent work plan, the OIG recommended more investigation, auditing and inspection of all healthcare providers,” said Kim Skehan, SimiTree Director of Compliance, Regulatory and Quality.

Identify vulnerabilities with a full assessment
The best safeguard against payment-related audits is a well-trained staff operating with the regulatory knowledge to avoid billing errors and insufficient documentation that flag providers for audit.

“Many behavioral health providers trust their billing and revenue cycle management to Infinity because they want the reassurance that comes from outsourcing to a trusted partner,” said Eloy Paez, Executive Vice President, INFINITY.

“Having an expert and knowledgeable staff handling the revenue cycle provides some insulation against payment related audits in addition to expediting claims processing, improving cash flow and offering a host of other benefits to the provider,” Paez said.

Through its strategic partnership with SimiTree, INFINITY is also able to offer full compliance assessments to identify risks so that providers can correct their clinical, quality and billing vulnerabilities, using training where needed to shore up compliance.

“There has probably never been a better time for a full compliance assessment than right now, in light of the OIG directive and numerous other signs that Medicare is looking more carefully at providers,” SimiTree Senior Manager Laurie Newlun said.

Each compliance assessment by SimiTree carefully examines billing processes to ensure that medical records are meeting clinical requirements for Medicare or Medicaid eligibility as well as medical necessity.  “We look for the same things auditors will look for,” Newlun said.  “Errors, omissions, and patterns associated with improper payments. ”

SimiTree’s full compliance assessment evaluates other aspects of compliance as well. In addition to examining how well the behavioral health provider meets billing and payment requirements, SimiTree experts review compliance with HIPAA and Medicare Conditions of Participation (CoPs) requirements.

The assessment includes corrective plan recommendations, with additional compliance and regulatory implementation support.

Staffing shortage may increase risks
The OIG directive isn’t the only reason behavioral health care providers are encouraged to schedule full compliance assessments. As providers continue to struggle with employee retention during the ongoing labor shortage, a new window of compliance vulnerability has opened.

“Knowledge deficits and misunderstandings about regulatory requirements tend to occur with greater frequency during times of high turnover,” Newlun said. “When key leadership positions go unfilled, the organization may not have the knowledgeable oversight in place to make sure all regulations are being followed.”

The staffing shortage may also place behavioral health providers at increased risk for investigations due to complaints made by patients, their representatives, or their families who are unhappy about wait times for services and other issues caused by being short staffed, Newlun said. Having a full compliance assessment and addressing any issues makes a provider less vulnerable when such investigations occur.

Help for audits and appeals
If your behavioral health program is targeted for a payment-related audit, SimiTree compliance experts have the experience to help you navigate the audit and appeal process. The compliance team is made up of clinical experts certified in healthcare compliance with extensive experience in government audits and appeals at all levels, including expert witnesses in Administrative Law Judicial proceedings. In addition, current, former, and certified surveyors provide best-in-the-industry comprehensive compliance and regulatory support to meet an organization’s needs.

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