Payor Audits: Current Audit Issues and Strategies to Avoid and Defend Audits

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About Course

Format: Live Webinar
Presenter: Jenna K. Godlewski and Alice V. Harris
Event Date: 06/21/2023
Time: 3 pm ET | 2 pm CT | 1 pm MT | 12 pm PT
Duration: 60 minutes

Conference Materials (Password Required)

This webinar will focus on giving healthcare providers tools to prevent and defend payor audits. The different types of federal and state auditors who audit payor claims will be examined, including the Office of Inspector General (OIG), Medicare and Medicaid Recovery Audit Contractors (RACs) Supplemental Medical Review Contractors (SMRCs), CMS Targeted Probe and Educate (TPE), Unified Program Integrity Contractors (UPICs), and Medicare Administrative Contractors (MACs). Audits conducted by commercial and managed care payors, as well as state and federal prosecutors will also be discussed. Website links will be provided that identify the current audit focus of these auditors, and these current topics will be discussed.

The webinar will also provide healthcare providers with tips on how to organize and submit the documentation requested at the beginning of a payor audit with focus on how to ensure that the complete medical record is produced in an easy-to-review format. This segment will also focus on in-house strategies providers can use to ensure that their staff understands how to handle the receipt of a payor audit request or findings.

In addition, the webinar will give strategies to healthcare providers on how to analyze and defend a payor audit. This segment of the webinar will focus on how to conduct an initial analysis to determine if an appeal should be made, and if not, what corrective actions the provider should make because of the audit findings. Economic, legal and clinical considerations will be discussed. This segment also will provide tips on potential experts to use to bolster appeal arguments. Finally, this segment will provide effective arguments to make to defend payor audit findings using LCDs, clinical tools, statutes and regulations, payor policies, and case law. Tools for how to potentially challenge a statistical extrapolation will also be discussed.

Finally, proactive compliance and preventive measures will be examined to assist healthcare providers with avoiding being the target of a payor audit, including performing baseline audits, conducting ongoing risk assessments, educating providers and staff and evaluating billing contractors.

Learning Objectives:

  • Understand the different federal and state entities that can audit payor  claims submitted by providers
  • Teach providers how to find current audit topics in order to know if  their practice is at risk for audits and why
  • Teach providers how to effectively submit the documentation requested in an audit
  • Provide tips for providers on how to effectively manage and defend payor audits
  • Provide preventive measures that can help providers avoid payor audits

Areas Covered in the Session

  • Who is Auditing Claims
  • Where to Find Current Audit Topics
  • How to Submit Documentation if Audited
  • How to Manage and Defend Payor Audits
  • How to Prevent Payor Audits
  • Live Q&A Session

Suggested Attendees

  • Healthcare Executives CEOs, CFOs, COOS
  • Healthcare administrative personnel
  • Healthcare providers and staff
  • Hospital and healthcare facility administration
  • Physician and Non-Physician Practitioners
  • Nurses
  • Physician Assistants
  • Billing and Coding Staff
  • Clinical providers
  • Office managers and staff at medical entities
  • Auditors
  • Compliance Officers
  • Clinic Managers
  • Practice Managers
  • Credentialing and Enrollment Specialists
  • Credentialing and Enrollment Specialists
  • Healthcare Administrative Personnel
  • Medical record supervisors
  • Health Information Management Administrators and Technicians
  • Legal counsel and other professional advisors to healthcare providers
  • Other Personnel Interested in Billing Privileges with the Medicare Program

About the Presenter

Jenna focuses solely on healthcare law and assists medical practices across the country on reimbursement, regulatory, and compliance matters. She helps clients reduce exposure, develop corrective action plans, and successfully appeal Medicare, Medicaid, and other federal payor recoupment claims. Another primary focus of her practice is handling CMS enrollment issues, payment suspensions, and revocation/exclusion appeals. Since joining the firm, she has also had the opportunity to assist clients with developing and restructuring their internal compliance programs.

Jenna works closely with the healthcare team on audit defense, overpayment appeals, credentialing matters, compliance analysis, and litigation support. Her clients include hospitals, health care systems, private physician practices, multidisciplinary practices, specialty practices, home health agencies, skilled nursing facilities, hospice agencies, and laboratories.

Jenna served for three years as a prosecutor for the City of Chicago where she handled over 100 cases at a time from filing through resolution. This experience has been beneficial in her current work of representing her clients in Administrative Law Judge hearings to appeal Medicare overpayments and in supporting her colleagues on healthcare litigation matters.

Alice Harris is an experienced health care, reimbursement, and compliance attorney based in the firm’s Columbia, South Carolina office, where she assists hospitals, health care systems, physician practices, skilled nursing facilities, hospice agencies, home health care agencies, and other health care providers with a wide variety of matters. Her practice focuses on healthcare regulatory compliance, payor audit appeals and defense, reimbursement, billing and coding, COVID-19 advice, compliance program guidance, response to federal and state contractor audits, internal investigations, fraud and abuse analysis and litigation matters, federal and state survey and certification matters, Medicaid Cost Report appeals, EMTALA investigations, transactional compliance due diligence, and other health care regulatory and litigation matters.

Alice has experience handling overpayment and extrapolated overpayment appeals related to Medicare, Medicaid, and Commercial payor audits, including UPIC, ZPIC, MIC, and other contractor audits. She also assists providers with proactive compliance assistance to reduce exposure to audits, as well as root cause examinations and the development of corrective action plans to address underlying issues related to ongoing payor audits.

Her compliance analysis and advice experience ranges from initial formation and restructuring of compliance programs, including policy and procedure development, to internal investigations, potential whistleblower exposure, and coordination of ongoing coding reviews.

Course Content

You can access all the webinar materials after successful payment

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