Questionable and Aberrant Healthcare Billing Practices That May Trigger an Audit
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Speaker : DOROTHY STEED
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When : Tuesday, March 25, 2025
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Time : 01 : 00 PM EST
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Dorothy Steed is an Independent Healthcare Consultant and Educator. She has served as a Medicare specialist and a physician audit supervisor for hospital systems with 49 years of experience in healthcare. She is an instructor at a state technical college and provides auditing & training in both facility and physician services. She is credentialed in medical coding, medical billing, medical auditing, utilization management, healthcare management, healthcare compliance, clinical documentation improvement, revenue cycle and patient accounts. Additionally, she has participated in multiple healthcare audits and investigations for both plaintiff and defendant, She has provided review services for 2 state QIO organizations andserved as an expert witness in several legal disputes. She holds a Master’s degree in Strategic Leadership Development
Payer audits are on the rise, including Medicare, Medicaid, and private payers. Regardless of whether violations are found, audits are time consuming, disruptive, and expensive. The sophistication of claims processing edits, provider profiling and questionable billing patterns all contribute to identification of unusual coding and billing. When documentation does not support the codes billed, providers are often liable for recovery of funds and possible penalties. This presentation will discuss situations that cause payers to scrutinize providers for possible audit activity.
Avoid costly disruptions and revenue loss by understanding how payers identify areas of concern and initiate potential audit activity & provider scrutiny.
Areas Covered
- Payer system edits
- Diagnosis vs procedure
- Specialty and Evaluation & Management
- Minimal coding variations
- Unrealistic number of units
- Discrepancies in written chart & EMR
- Discrepancies: hospital, physician, anesthesia
- Lesion size
- Failure to state time
- Repeat billing; no resolution of errors
- Inappropriate modifier use
Who Should Attend
Billers, coders, revenue cycle staff, denial management staff, clinical documentation staff, physicians, midlevel providers, and risk management staff.
Why Should You Attend
Who Initiates Audits? Protect Your Revenue!
Audits may be initiated by payers, State Medical or Health Boards, whistleblowers, patients, and other parties. Claims are fair game for audit activity upon claim submission. Heavy reliance on system prompts without adequate training often leads to questionable patterns that do not meet acceptable reporting. Learn what payers expect and reduce costly rejections and denials.
Topic Background
Many providers have seen an increase in denials, requests for records, rejections, and other activities that create revenue delays and possible revenue loss. Learn areas that are likely to initiate these negative outcomes and improve the protection of your reimbursements.
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$160.00
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