Prescribing the right thing for Electronic Data and Administrative Billing,Disciplinary Issues.

Since the Centers for Medicare Services started the audits as an experiment in 2005, they are now permanently part of the healthcare reform landscape.

The audit recovery process started as a demonstration project in Florida, California and New York, the states with the highest percentage of medicare.  The program worked nicely, so it was expanded to Mass, South Carolina and Arizona,

Ultimately netting close to 700 Million in reimbursements, penalties, fees from discovering billing errors and abuses. A law in 2006, made these audits a permanent part of our government program of billing reviews.

These Audits, the visits by the Recovery Audit Contractors seem like visits from people bent on taking the physician’s money away.  There are real abuses and mistakes, which justifies the program, and physicians should be prepared to respond.

There should be a person within the medical group designated to respond and to follow the requests, guide the appeals and document the billing clearly defining codes, services, dates, patients, etc.

Remember that the auditors are paid a percentage of what they collect from the physician’s offices.

The four steps involved with an appeal are:

  •  Rebuttal and discussion period. This is a chance for providers to have an open dialogue with the contractor. It doesn't extend the deadlines. ..but it helps in the appeal process and result…providers have been making "substantial progress in the earlier stages of the review."
  • Redetermination. This is the first step in the appeals process, and a provider has 120 days to file a request for redetermination. Reconsideration. After the redetermination decision, a provider can submit for a reconsideration within 60 days to avoid withhold of payment. At this stage a provider can submit additional evidence for review.
  •  Administrative law judge hearing. A request for an ALJ hearing must be filed within 60 days of the reconsideration decision, and the hearing can be conducted by phone, video conference, or in person.  

The Doctors’ Insurance Agency provides the important coverage to help in the event of such an audit.  Email, text or phone now to obtain a bind able offer on this important coverage for physicians and their offices.

Regulatory issues. Patient Privacy challenges. Do your physicians have the coverage they need?

Medefense™ Plus, our Billing Fraud & Abuse products from NAS.

Medefense™ Plus offers



A cutting edge suite of coverages designed to handle governmental regulatory agencies, such as RAC, EMTALA, Stark, etc., and patient privacy challenges.

Access to expert panel of attorneys and experienced claim experts that will handle the claim from start to finish.

Support from specialized vendors , experts accustomed to responding to administrative, disciplinary, and billing issues against physicians.  They can customize services to fit their needs.

 The MedDefense product is available to all TDC policyholders for $ 1,500 for a small, one doctor policy.

This is for an additional 1 Million of this important Regulatory, Disciplinary and timely billing fraud and abuse coverage.

Comments are closed for this post, but if you have spotted an error or have additional info that you think should be in this post, feel free to contact us.
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