One of the recommendations for avoiding the pain of a Medicare audit is to put a plan in place to ensure that the organization is following best practices for creating and submitting claims. Read through the article. Then imagine that you, as an HIM Professional, were asked to put together a similar plan. In a four-paragraph Word document, identify steps you would implement to minimize the chance of being subjected to a Medicare audit. Name the file “MedicareAudit”

Title: Minimizing the Chance of a Medicare Audit: Steps for HIM Professionals

Introduction:
Medicare audits can be a time-consuming and potentially costly process for healthcare organizations. In order to minimize the chance of being subjected to a Medicare audit, it is crucial for HIM professionals to proactively implement steps that follow best practices for creating and submitting claims. By adopting a comprehensive and well-planned approach, organizations can ensure compliance with Medicare guidelines, reduce errors and discrepancies, and mitigate the risk of an audit. This document outlines key steps that HIM professionals can take to minimize the likelihood of a Medicare audit.

Step 1: Establish Compliance Policies and Procedures
The first step in minimizing the chance of a Medicare audit is to establish robust compliance policies and procedures. HIM professionals should develop a comprehensive set of guidelines that align with Medicare requirements and industry standards. These policies should cover various aspects of claims creation and submission, such as documentation requirements, coding standards, and billing practices. It is essential to frequently update these policies to reflect any changes in Medicare regulations or coding guidelines. Additionally, HIM professionals should ensure that all staff members are trained on these policies and procedures, reinforcing the importance of compliance throughout the organization.

Step 2: Implement Effective Documentation Processes
Accurate and complete documentation is paramount to minimizing the risk of a Medicare audit. HIM professionals should implement effective documentation processes that adhere to Medicare guidelines. This includes ensuring proper record keeping, including all relevant patient information, medical history, diagnostic tests, procedures, and treatment plans. Utilizing electronic health record (EHR) systems with built-in templates and prompts can help facilitate consistent and accurate documentation practices. Regular audits of documentation should be conducted to identify any areas of non-compliance or potential weaknesses in documentation practices.

Furthermore, HIM professionals should emphasize interdisciplinary collaboration to ensure that all pertinent healthcare providers contribute to the complete and accurate documentation of patient encounters. This includes encouraging effective communication among physicians, nurses, therapists, and other staff members involved in the delivery of patient care. Improved interdisciplinary collaboration can help minimize errors, reduce missing or incomplete documentation, and improve the overall quality of claims submission, thereby lowering the likelihood of a Medicare audit.

Step 3: Conduct Regular Internal Audits and Reviews
To identify and address any discrepancies or non-compliance issues early on, HIM professionals should conduct regular internal audits and reviews. These audits should encompass various aspects of claims creation and submission, including coding accuracy, billing practices, and documentation completeness. Through internal audits, HIM professionals can proactively identify areas of non-compliance or potential risks, allowing for timely interventions and corrective actions.

During internal audits, HIM professionals should pay particular attention to areas that have historically raised concerns or have high audit vulnerability, such as evaluation and management (E&M) coding, durable medical equipment (DME) claims, or outlier cases. Regular audits enable HIM professionals to assess the accuracy of coding and billing practices, identify any recurring patterns of errors or discrepancies, and implement targeted training or process improvements to address these issues effectively.

Step 4: Engage in External Reviews and Compliance Assessments
In addition to internal audits, engaging in external reviews and compliance assessments can provide an added layer of assurance to minimize the chance of a Medicare audit. HIM professionals should consider hiring external consultants or organizations specialized in auditing and compliance to conduct periodic assessments and identify any potential compliance gaps or areas of concern. These external reviews can help validate the effectiveness of internal auditing processes and provide an unbiased evaluation of an organization’s adherence to Medicare regulations.

External consultants can also offer valuable insights into industry trends and emerging best practices, ensuring that organizations stay current with evolving compliance requirements. Recommendations from external reviews should be reviewed and implemented as appropriate, further enhancing an organization’s compliance strategies and minimizing the risk of a Medicare audit.

Conclusion:
Minimizing the chance of a Medicare audit requires a proactive approach from HIM professionals. By implementing steps such as establishing compliance policies and procedures, implementing effective documentation processes, conducting regular internal audits and reviews, and engaging in external reviews and compliance assessments, organizations can significantly reduce the likelihood of a Medicare audit. These steps not only promote compliance with Medicare guidelines but also improve the overall quality of claims creation and submission. Through ongoing vigilance and commitment to best practices, HIM professionals can mitigate the risk of a Medicare audit and ensure the smooth operation of healthcare organizations.