Transcript Slide 1

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)
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:
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case management
healthcare informatics
charge data master review
healthcare reimbursement
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cost containment
special investigations
health information management
utilization management
Is this definition still relevant in today’s practice?
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?
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
04/10/14
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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
How Can AAMAS Help You?
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Education
Conferences
Regional Meetings
Webinars
Newsletters/E-blasts