Providers: get ready for audits. The Centers for Medicare & Medicaid Services (CMS) are aiming to clean up billions of dollars in over payments with a variety of auditing initiatives in coming months. This has prompted new initiatives for Medicare and Medicaid related audits of both payers and providers which can lead to costly administrative work in hospitals. We take a look at some recent developments and healthcare compliance management software solutions.

Healthcare Compliance Management Software

As CMS readies a number of auditing initiatives, healthcare compliance management software is becoming more crucial for hospital compliance officers and revenue integrity team members.

Findings Of Billions in Overpayments Healthcare Compliance Measures

Healthcare Dive is reporting that, CMS Administrator Seema Verma “told reporters…that the new audits, set to begin later this year, are partially in response to Office of the Inspector General findings in Kentucky, California and New York, as well as from the Government Accountability Office (GAO).  In its report, GAO recommended that CMS take steps to mitigate Medicaid overpayments not being properly measured by revising the Payment Error Rate Measurement methodology or by focusing additional audit resources on managed care.” IIn a related RevCycle Intelligence article, it is reported that the Centers for Medicare & Medicaid Services’ poor provider screening process allowed ineligible providers to collect $59B in 2015.  $59 Billion, talk about financial incentives for upcoming audits. This research has been going on for a few years and now looks to be folding in with initiatives in the new administration. Tracey Tillman, Product Manager for SSI Audit Director, advises that your facility must first “determine a strategy to address the complexity of audits. Within the response strategy you’ll have a need to standardize your workflow for end-to-end tracking and automate as much as you can to work efficiently.”  She notes that healthcare compliance management staff range from using “a self-developed tool to spreadsheets to sometimes working with a vendor. The key is “managing the increasing number of audit requests within a centralized system.” Within the SSI Group client database, one good trend is that “62% of claims that undergo a CMS appeal process are overturned in favor of the provider,” reports Tillman.  “You should appeal to avoid leaving money on the table.” And, SSI Audit Director provides reporting and trending of your data.  “SSI’s Billing, Denials, Audit and Appeals process offers a comprehensive solution to assist our customers in identifying and reducing the dollars at risk during a medical record review process. Our Audit and Appeal tools include automated esMD for efficient and accurate transmitted data.”  We asked Ms. Tillman how this solution integrates into well-known hospital information systems:  “The esMD gateway is a way to automate data and push it back to Medicare. You need a certified HIH (Health Information Handler) and The SSI Group is one of the few that offers such a data clearinghouse. Hospitals can really streamline on this step. You will submit data to a regional review company hired by CMS and may do so  promptly and efficiently.”
Tillman also explained that, “For your appeals management and strategy, this is a big win for revenue cycle teams where 62% of proper appeals will be overturned. We can identify letters that have won appeals and put them into your process to recoup revenue.”At left, is a list of medical documentation request types encountered during audits from a recent webinar by the SSI Group with Tracey Tillman.  Note that while most documentation sent is still via paper or fax, that the SSI Audit Director healthcare compliance management software enables electronic submission of medical documentation (esMD) to save related time and expense.


The SSI Group offers a new healthcare compliance software called SSI Audit Director.  Now your organization can quantify risk and gain insight into the root cause of problems – dollars at risk, win/loss, denial trending, and more – via advanced reporting features. Includes simplified tracking of all commercial payer, Medicaid and CMS Medicare audits. Our software solution does not rely on a third-party for claim and remit data, since The SSI Group provides its own clearinghouse. Your team will protect revenue and reduce future take-backs of previously collected dollars.  Save time by automating workflows to simplify compliance with audit requests. Audit Director may be used by all types of healthcare facilities, large and small, from acute care to long term health facilities including rehab, nursing homes, etc.

RevCycle Intelligence writes about the financial incentive for these audits.  The editors observe “Medicaid spending rapidly increasing from $456 billion in 2013 to an estimated $576 billion in 2016”,  and that “CMS decided that now is the time to strengthen the relationship between the federal government and states to ensure Medicaid program integrity.”  The article continues detailing three new CMS initiatives to prevent Medicaid fraud and improper payments:

  1. CMS plans to improve Medicaid program integrity through audits of state claims for federal match funds and medical loss ratios.  Some states will undergo audits based on the amount spent on clinical services and quality improvement activities versus administration and profit.
  2. CMS will conduct new audits of state beneficiary eligibility determinations. The federal agency intends to target high-risk states according to OIG standards and assess how they determine which populations are eligible for Medicaid benefits.  The audits will also evaluate the impact Medicaid expansions have had on program integrity, as well as the effect of the enhanced federal match rate on state eligibility policy.
  3. CMS announced that its plans to improve claims and provider data submitted by states. Every state plus Washington DC and Puerto Rico is now submitting comprehensive data to CMS. In light of this milestone, the federal agency wants to validate the quality and completeness of the data to improve Medicaid eligibility and payment information.  Advanced analytics and other HIT tools will be key to optimizing the state-provided data to maximize its potential use for program integrity improvements, the announcement stated.

While these three initiatives show audits at the state level, we believe they will spill over into provider audits, particularly in light of what is mentioned further down in the article including mandates to:

  • Educate Medicaid providers to reduce improper payments and medical billing
  • Offer provider screening on behalf of states on an opt-in basis

“It is ultimately on the provider to identify and prevent these types of review from going forward,” explains Tracey. “If the provider is tracking improper payments, Medical billing, Coding errors and other related data, they can analyze and trend, to prevent future reviews.

You can get proactive ahead of any audit notices your organization may receive,” stresses Tillman. In general SSI Audit software, can assist in proactively tracking and trending your data, so you can prevent any unnecessary reviews. There’s a lot of improper payments that result from improper training. For example in the ER area, you might uncover you have more reviews that occur on the weekends, due to training or personnel staff not documenting correctly.

We have a lot of facilities that look at historical data to find coding and documentation errors and with proper cross department training can work to eliminate these or reduce their reviews.”

The US GAO spells out the need for reviews very clearly.  “GAO identified weaknesses in CMS’s verification of provider practice location, physician licensure status, and criminal-background histories,” said Seto J. Bagdoyan, GAO’s Director, Forensic Audits and Investigative Service. “These weaknesses may have resulted in CMS improperly paying thousands of potentially ineligible providers and suppliers.” New Initiatives for CMS Medicare Related Healthcare Audits Meanwhile, in a newer articleHealthLeaders Media details eight new initiatives under an article entitled, “CMS Promises Targeted Medicaid Audits, Stricter Enforcement”. They are:

  1. Targeted audits of certain state MCOs
  2. New audits of beneficiary eligibility for state
  3. Claims and provider data optimization: In the coming months, CMS will validate the quality and completeness of state-provided data in the Transformed Medicaid Statistical Information System (TMSIS)
  4. Data analytics pilots: In addition to running analytics on state-provided data, CMS will help states themselves use data analytics to identify areas that need additional investigation
  5. Provider screening on an opt-in basis: The federal agency will pilot a plan to screen Medicaid providers on behalf of states.
  6. State-federal data sharing and collaboration: CMS is giving states access to the Social Security Administration’s master file of death records to help with managing provider enrollment.
  7. Publicly report state performance: The Medicaid scorecard was released to show how well states perform on certain measures pertaining to their Medicaid programs.
  8. Provider education to reduce improper payments: In an effort to reduce incorrect billing, CMS will bolster education efforts for Medicaid providers. This will include education targeting comparative billing reports and provider-facing tools currently in development.

These initiative some as the pressure on Medicare government administrators seems to be increasing. In an Epoch Times article, Seema Verma, the administrator for the CMS, said “the open-ended nature of the program, combined with it paying at least 90 percent of the costs for certain Medicaid patients, has put the program on an unsustainable path.” The article continues, noting that, “last year, the federal government spent about $430 billion on the program, according to the Congressional Budget Office. That’s about 72 percent of the program’s entire cost, which it shares with the states. An estimated $37 billion of that was for improper payments, a mix of clerical errors and fraud, which was the subject of the hearing. And the Congressional Budget Office estimates that expenditure on the program will grow about 5.5 percent a year, making the federal government’s portion about $655 billion by 2028.” Resources for Healthcare Compliance Management:

  • CMS has prepared a complete list (PDF) of these and other auditing initiatives in near future.
  • American Academy of Professional Coders(AAPC) offers the Certified Professional Compliance Officer(CPCO™) credential to help address the ever-growing compliance requirements of government laws, regulations, rules, and guidelines.

Read more about Audit Management in a series of articles prepared by your SSI Group editors.