This document discusses how healthcare providers can prepare for and respond to audits from regulatory agencies. It recommends developing compliance programs, conducting internal audits, and preparing documentation in response to audits. It also outlines the five-level Medicare appeals process and tips for appealing unfavorable audit results, such as establishing a multi-disciplinary appeals team and reviewing every denied claim. The Fox Group is a healthcare consulting firm that can help providers comply with audit requirements and minimize future exposure through risk-based coding audits and training programs.

1. CONSULTANTS TO THE HEALTHCARE INDUSTRY
Part of the Fox Informational Series
February 13, 2010
PREPARING FOR AND RESPONDING TO AN AUDIT
AND APPEALING UNFAVORABLE RESULTS
With all the agencies out there whose purpose it is to review, audit, evaluate, assess and, if called for,
prosecute providers who are not in "compliance", the likelihood having one of them scrutinize your
work has never been higher. So, with all the added activity by these agencies, how prepared are you to
know how to handle an audit notice from one of them?
Consider the following …
Importance of Compliance Programs
Develop policies and procedures for responding to audit request
Conduct frequent education and training on coding and billing practices
Perform regular internal and/or external audits
Conduct own data mining
Correct problems identified in audits
CMS Suggestions for Preparation
“To prepare for the start of the (audit) programs (i.e. RAC), health care providers should consider
conducting an internal/external assessment to ensure that submitted claims meet the Medicare rules.”
Responding to Audits
Provide complete documentation
Don’t rush the process, BUT meet deadlines
Don’t sign statements certifying completeness of records until confirming that all documents
have been provided
Retain or request a copy of all documents provided to contractor
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Copyright 2010

2. Medicare Five‐Level Appeal Process
Redetermination from the Intermediary/Carrier
Reconsideration from a Qualified Independent Contractor
Appeal to an administrative law judge
Appeal to the Medicare Department Appeals Board
Appeal to a federal district court
Tips for Appeals
Be prepared to appeal
Know the appeal timelines and requirements for each appeal level
Understand reasons for denial at each level of appeal
Be aware of recoupment timing
Establish multi‐disciplinary appeals team (billing, compliance, medical staff, case management,
utilization review, legal)
Review EVERY claim for possible appeal
o Procedural – Did (auditors) follow rules?
o Substantive – Was claim medically necessary?
Obtain outside reviews (medical, coding, statistical) as appropriate
Develop standard templates for specific denials
The Fox Group has over two decades of experience helping providers who are experiencing an increase
in audits to fully and efficiently comply with the audit requirements, and to establish internal systems
that will minimize future exposure. Our team of professionals can help keep your compliance efforts on
track with a risk based coding audit and training program that will not only help keep you off the “audit
radar”, but will have welcome byproducts such as well supported billing and a consequential speedier
collection of billed charges.
The Fox Group, providing excellence to the healthcare community since 1989.
The Fox Group is a healthcare consulting firm Contact us at …
serving physicians, hospitals and other diverse 909 . 931 . 7600
healthcare providers throughout the U.S. and contact@foxgrp.com
abroad to achieve their strategic, operational,
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