Medical Audit: Past, Present and Future

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Medical Audit Past, Present and Future
An AAMAS Panel Presentation Ruth Gahan RN BSN
CMAS (moderator) Marilyn Balcita RN CMAS CPUR
CICA Laura Dale RN BSN E Jonas Blomqvist
CMAS Ruth Wingfield RHIA, CCS, CCS-PA, AHIMA (in
absentia)
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Medical Audit Today Audience Participation
Medical Audit Definition (coined around
2008) Medical Audit is a process that is
integrated throughout the revenue cycle to meet
the national healthcare compliance standards.
Its scope includes but is not limited to
case management healthcare informatics charge data master review healthcare reimbursement cost containment special investigations health information management utilization management
Is this definition still relevant in todays
practice?
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Future of Medical Audit?

• Changes in healthcare delivery impacting
  reimbursement
• Commercial and government based
• Quality care measures
• Impact of ACA
• ICD-10
• Technology and systems impact
• Are you ready to face the new challenge?

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Take-away ? Keywords
2-MN rule Medical necessity review Teach and Educate vs Probe and Educate Sampling Rules DME-SNF-Home Health audits Attestation and Signature requirements Appeals vs Grievance vs Complaint Denials Medicare-Medicaid Post payment recoupment Data Mining Medicare Manuals/CMS Medlearn ICD-10, CPT/HCPCS , CCI-NCCI Revenue Neutrality Enforcement Emergent technology Error prevention Pharmacy review ACO - Bundled Payment Part C and D review Contract compliance Presumption and Benchmarks ERISA - PPACA Eligibility/Rescission Assignment of Benefits/Coverage Commercial screening criteria NCD, LCD, clinical guidelines Organization determination Adverse determination URAC NCQA - State mandates Data and Cost Benefit Analysis Pay for Performance Revenue Integrity
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• Education
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• Regional Meetings
• Webinars
• Newsletters/E-blasts