Medical Audits: What Physicians Need to Know

Government and private payers have increasing pressure to lower healthcare costs. This inevitably drives them to audit practices for alleged overpayments and to attempt to recoup. It is imperative that physicians understand the risk of these audits, how to prepare and how to respond. Physicians need to prepare for and manage external payer audits just as they manage any other part of the business side of their practices to minimize the risk of being audited and to ensure that any audit findings are fair and accurate.  Read a comprehensive white paper prepared by the Physicians Advocacy Institute (PAI) and share it with your staff.

PAI is a non-profit advocacy organization established in 2006 with funds from the class action settlement agreements against major national for-profit health insurers. MSNJ was a signatory on each of the national class-action lawsuits and actively engaged in enforcing compliance. Larry Downs, MSNJ’s CEO and General Counsel, is a member of PAI’s compliance committee.

PAI’s mission is twofold: to guarantee compliance with the national class-action settlement agreements and to work with the settling health insurers to encourage voluntary compliance with the settlements after their expiration; and, to develop projects and tools that guarantee the viability of physicians’ medical practices and the ability of physicians to deliver quality patient care.

PAI’s new audit tool will:

  • assist practices in determining their risk of being audited
  • describe the various type of audits
  • discuss the audit process
  • discuss how to respond to an audit
  • provide tips to analyze audit findings; and
  • provide guidance on how to appeal any adverse audit determinations.

Significantly, the tool provides information on extrapolation and the manner in which to test the validity of an extrapolation methodology. Frank Cohen, MPA, MBB, of The Frank Cohen Group, LLC, is an author of the white paper. Frank Cohen previously made a presentation to MSNJ on audits in a webinar format. Review the slides from his presentation.

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About MSNJ

Founded in 1766, the Medical Society of New Jersey is the oldest professional society in the United States. The organization and its dues-paying members are dedicated to a healthy New Jersey, working to ensure the sanctity of the physician–patient relationship. In representing all medical disciplines, MSNJ advocates for the rights of patients and physicians alike, for the delivery of the highest quality medical care. This allows response to the patients’ individual, varied needs, in an ethical and compassionate environment, in order to create a healthy Garden State and healthy citizens.

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