AAOS Now

Published 12/1/2014

What You Should Know About Audits

The Centers for Medicare & Medicaid Services (CMS) has intensified its Medicare audit programs in various jurisdictions across the country. Three types of audits can occur: Comprehensive Error Rate Testing (CERT), Recovery Audit Contractor (RAC), and Zone Program Integrity Contractors (ZPIC) audits.

Here are some key facts orthopaedic practices should understand about Medicare audits.

Not all audits are the same
Each of the three types of audits is looking at something different.

  • CERT audits are designed to measure the number of improperly paid claims so that Medicare can determine its improper payment rate.
  • RAC audits are designed to detect and correct past improper payments so that CMS and other insurance carriers, fiscal intermediaries, and Medicare Administrative Contractors can implement actions to stop future improper payments.
  • ZPIC audits are responsible for detecting and deterring fraud, waste and abuse across all claim types.

It is important to respond quickly to an audit request. Audit requests allow 45 calendar days from the date of the audit letter for practices to submit either a request for an extension or the records requested.

If you receive an audit letter…
If a practice receives an audit letter, it should take the following steps in responding to the request:

  • Determine which type of audit request has been received.
  • Immediately send a “statement of opportunity to rebuttal.” Practices have only 15 days from the date on the audit letter (not the date you receive the letter) to request this opportunity, so don’t delay.
  • Request an extension.
  • Alert the practice attorney.
  • Review documentation and begin to build a defense, citing CMS 1995/1997 documentation guidelines, the Medicare Claims Processing Manual, ICD-9/ICD-10, and CPT coding guidelines.
  • Review all charts before submitting them to the carrier. Be certain that everything that could support your claim is included.
  • Send documentation with a ‘return receipt requested.’ This proves evidences of delivery and the date delivered.
  • Only send documentation for the dates of service requested.
  • Appeal the findings of the audit. Complete a CMS Redetermination form and submit it to the CMS intermediary. (Five levels of appeal are available.)
  • Implement corrective action.

The request for documentation received can be vague, and it may be difficult to determine which type of audit is being conducted. The American Hospital Association has sample demand letters on its website (www.aha.org) that can help practices determine which entity (CERT, RAC, or ZPIC) is requesting the audit.

Additional Information: