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Whether they work for the government or a commercial insurer, all auditors look for basically the same types of things when reviewing health care claims for payment. Knowing what these audit keys are and how plans use them to avoid paying a claim can help your practice avoid snags in payment progress. Key factors to be aware of include:
1. Automated edits. Carriers use automated methods to edit or quickly check claims for obvious inaccuracies or incomplete information that will kick the bill back to the provider to be fixed.
Be warned that a pronounced pattern of extensive or similar mistakes can prompt a carrier’s computer to "red-flag" the practice for a more extensive audit. Depending on the pattern identified, investigators might decide to look at all the recent claims submitted by a particular provider, focus on a certain kind of claim filed by a specific physician, or tag all the claims submitted for an individual beneficiary.
Some of the common mistakes carriers look for in these first-level edits which can get your claim denied and kicked back include:
Carriers often collect this kind of information on a specific provider for 18 months to four years to try to identify a particular pattern of questionable denials — or a billing profile that is out of sync with other providers. If a red light does go off, auditors may want to pull your records for a closer look at your billing history.
High on the list of activities that make investigators suspicious is the appearance of an unusually high claim volumes for a specific CPT code or kind of service. What looks to be a superhuman level of billings for one person during a given 24-hour period or work week for certain services or individual patients will also raise eyebrows among claim examiners.
2. Prepayment review. The next step in the audit food chain is the prepayment review, where the carrier sets aside certain types of claims by a particular provider for closer examination before payment.
The good news is that if you do not receive further communication from the carrier fairly quickly asking for more information about a claim, it probably found nothing and the bill is being paid. But if reviewers find what they feel are questionable claims, these will be set aside for a closer look — and possible fraud and abuse investigation.