There may come a time when a health care provider will receive a Medicaid Program audit notice. Everything requested needs to be correctly provided when responding to the notice. These types of audits are an attempt to identify any problematic legal issues that could be present within a medical program. Response to the questionnaires must be accurate. All medical records provided need to be organized, easy to understand, legible, and complete.
The audit formula utilized by Medicaid is designed to calculate any and all overpayment amounts. A positive audit may avoid any type of penalty assessment or repayment requirement by Medicaid. It’s important to realize if an audit results in a demand for overpayment, it is still possible to negotiate the results. An acceptable repayment schedule or settlement may be able to be reached.
When a medical program is being audited by Medicaid, they will receive a notice of the audit from an auditing agency. The agency will provide a list of patients for their sample. Up to 50 patient’s records could be requested for the audit. The audit notification will also come with a questionnaire that needs to be completed. A Certification of Completeness of Records form will also be provided. It will need to be completed and returned with copies of the requested patient records. It’s important to understand the due date on the form. This date isn’t the last day patient records can be mailed. This is the date the records must be with the auditing agency.
Once an audit request is received, it’s important to carefully review all the records that will be submitted to Medicaid. A complete patient record needs to be provided. It can’t be just parts of the from the time requested by the audit. Other physician records used as history, consultant reports, hospital reports and more should all be included. Physicians orders, history questionnaires, results of physicals and more are essential parts of a medical record for auditing purposes.
It is important to review the requested patient files prior to submission and address any possible issues. When issues are identified, it’s recommended the medical organization prepare a separate explanation. This should be submitted with the requested file. Doing this can help an audit reviewer assess if there is an actual issue. All explanations submitted with files should be clearly labeled. This will avoid any possible confusion about it being part of the patient’s actual medical record.
Should a medical organization take X-rays, or use any type of diagnostic study, or examination for treatment purposes, this also needs to be included with the patient’s record. The auditing agency may accept a patient’s X-rays, diagnostic studies and more on a compact disc.
It’s also important to include an explanation of any uncommon abbreviations used in notes or with other parts of the patient’s file. It is also a good idea to include an explanation of any clinical practice or other supporting documents so that all medical procedures and billing procedures are easily understood.