Healthcare – CMS Claims Audits

Medical Claims Audits (also referred to as Medical Records Audits, CMS Audits and Government Audits) embody significant risks to legitimate revenues and profit margins for healthcare providers and managed care organizations. These audits often include very complex appeals processes with stiff penalties such as the automatic recoupment of funds if appeals deadlines are not met. You need to be prepared with a system that can help you TAKE CONTROL of the entire audit process from the initial request for records, to timely replies, determinations and appeals. You also need the detailed information in hand to make well-informed decisions on proceeding with appeals. When appeals are filed, you need the ability to track all the critical dates and ensure that input from each department is received and processed in a timely manner.

The Compliance 360 Claims Auditor has been designed for managing a wide variety of claims audits including:

• Medicare Recovery Audit Contractor (RAC) audits
• Zone Program Integrity Contractor(ZPIC) audits
• Medicare Comprehensive Error Rate Testing (CERT) audits
• Medicaid Integrity Contractor (MIC) audits
• Medicaid Fraud Control Unit (MFCU) audits

With the Compliance 360 Claims Auditor, you can:

• Take control of the claims audit process to minimize the risk of losing your legitimate revenues.

• Automate the management of the entire claims audit process across all departments and create organizational accountability with highly configurable workflow.  With automated workflow, the Claims Auditor functions as your “Virtual Audit Coordinator”, enforcing deadlines and due dates throughout your organization and providing alerts that enable you team to avoid the automatic recoupment of legitimate revenues.

• Integrate all claims audits into your “Claims Audit System of Record”. Use the Compliance 360 Claims Auditor as your central location for managing all medical claims audits including RAC, MIC, MAC, CERT, PERM, MFCU, ZPIC and others.  With the Compliance 360 Claims Auditor, there is NO ADDITIONAL Cost, as you expand the use to incorporate all claims audits.  There is no need to purchase or install additional software.  The expansion is accomplished using configurable workflow capabilities and audit-specific workflow templates provided by Compliance 360.

• Make well-informed decisions throughout all your claims audit and appeals processes and proceed with appeals only when the outcome is likely to be successful.

• Provide executive visibility with real-time dashboards. Executives and other key decision makers can closely monitor the status of pending claims audits and appeals to gauge the overall financial exposure of active medical claims audits.

• Proactively establish barriers to claims auditors by demonstrating an “in control” status with efficient self assessments and internal defense audits.

• Incorporate claims audits into your broader compliance and risk management programs using the comprehensive Compliance 360 GRC platform. This is important for hospitals and healthcare systems seeking to address the increasing governance and risk management needs of their boards of directors and investors in today’s climate of increasing regulatory scrutiny and demands for oversight.

• Accomplish all of these objectives without installing or maintaining any software or additional computers. The entire Compliance 360 system including the Claims Auditor is provided as a secure Internet service that can be accessed from any location. Utilize complementary advisory consulting services to assess vulnerabilities and implement process improvements based on CMS guidelines. These services can also be used to assist with the defense of RAC Audits and preparation for appeals.

Demonstrations of the Compliance 360 Claims Auditor

To learn more about using the Compliance 360 Claims Auditor to manage your RAC audits and appeals we invite you to view a recorded demonstration of the system:

• Compliance 360 Claims Auditor Demonstration
  On-demand web demo

To request a personal demonstration of the Compliance 360 Claims Auditor, please Contact Us.

Free Claims Audit Training (Live and On-Demand Webinars)

You are also invited to attend our live broadcasts or replay our on-demand recorded training webinars at your convenience. These training webinars have been attended by more than 10,000 participants and have received very positive feedback.  Click Here for the full list of live and on-demand training webinars.

Learn More

To learn how leading healthcare providers are using Compliance 360 to minimize their compliance overhead and risks, and how you can be do the same, contact us today.