Audit based reimbursement recovery

 

This issue is likely to come up much later in the Implementation process. During the transition period the documentation requirements are increased so therefore it is inherent there is an increased risk of audit failure. Well what does this mean for you, well what it means is you may have been paid on a claim after the payers audit process, they may request the payment back. Why would this happen you may ask, well the main reason is the pa...yers are learning just as you are so that means they are constantly adjusting and also readjusting how they require claims to be submitted to them. You may also feel that this is nothing new payers do this all the time, well you are right and wrong on your response. You are correct in stating that payers do this all the time but this is part you may have not considered in your response. Say for instance the claims that they are requesting a refund on were paid out over 3 months ago, well because your office has assumed you are filing that claim correctly due to payments being made. Now you have a history in the office of assuming you were correct on how these code was documented, submitted, so you must not only start forward filing this code in a new manner but you must first alert the staff this affects, also it is necessary to add this information to your office library. On top of that the funds possibly will be taken out of a reimbursement check you were expecting which could possibly cause a hardship.