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Medicare Billing Audits

Medicare Billing Audits

Pre-billing audit processes are crucial to preventing revenue recoupment and even fraudulent billing criminal charges.

Anderson & Tuttle, LLC have been busy defending ADR denials for instance and legal nurse consulting for agencies facing criminal charges that could have all been avoided with a 10 minute check-and-balance process: The Pre-Billing Record audit.

For instance, we have seen agencies that have been submiting claims to Medicare for up to 7 years without ever having to justify the claims they were sending. This lead to a sense of complacency; Medicare wouldn’t let them screw up that much for that long, right? WRONG!

One agency had a wonderful program providing therapy services for instance. Good growth, good referral base. Only to discover that the services they were providing were not covered by physicians orders. (Eval and treat only pays for the eval, therapy orders MUST include frequency, duration, modalities, and intervention) To make matters worse, even if the physician had signed the orders, they didn’t follow their own plan. The final nail in the coffin was the particular therapy they were offering was not considered reasonable and necessary by their RHHI because it did not result from a new onset or exacerbation of disease.

They got a few ADRs, didn’t know what they were (most agencies don’t deal with them routinely) so they did not appeal which resulted in denials, the percentage of denials racked up until they were on total medical review. All the remittance advices for current services were $0.00 because it was being recouped from current claims.

More commonly, claims are denied because the physician signature is dated after the date the claim was created. That signature can be back on the chart in 3 days, but if the claim is created in 2, the claim is denied.

485’s without COMPLETE orders (frequency, duration, interventions) do not cover services an agency is being paid for, which for all intents and purposes looks incredibly similar to billing fraud. (Note: The REAL frauds usually drive better cars than those who just skip the billing audit process)

So make sure you have a tool, a process, that indicates that for the episode being billed the physician has signed and dated the orders (and all supplemental orders that indicate a change to 485). Make sure that all disciplines have specific orders. Make sure that you have provided the visits that are noted on the claim (some sort of calendar worksheet is necessary for this step) no more, and no less.

Caveat with software solutions: They are terrific at auditing schedulted, versus ordered frequency. However, signed orders can too easily be entered in error. Worse, some agencies will actually mark an order signed just to free up the bill knowing that the order has not been returned to the agency.
Software solutions can certainly make the apre-billing audit go faster, but does not take the place of a hands-on prebilling audit.

Pre-billing audits are not always done by a clinical person. Preliminary visit to order comparison can be done by support staff as well as signature confirmation. Utilize this resource when you can, but limit how many hands the pre-billing process has to touch.

Any quality management model will demonstrate that too many steps and too many hands lead to higher error rates.

Lastly, and most importantly, when you get that first ADR (or 5th or 50th) CALL SOMEONE who deals with support and appeals processes regularly. Smaller agencies in particular will have a difficult time reaching that paid vs denial threshold simply due to sample size and a few ADR’s can turn into a cash flow nightmare quickly.

Get info on and download our new billing tool here.



  1. Galina Lenar says:

    Great tool! We have created something simmilar. I just have one question for you. I have never heard that Physical Therapy Eval has to be signed by physician. Is it specific for certain states? I am in Illinois.

  2. greatly appreciate you posting the tool!
    Thank you 🙂

  3. In response to the PT eval question. Alot of agencies (if not most) utilize the PT eval form as a supplemental order covering their PT services.
    Generally, the PT eval is completed after the 485 is already being processed and since you MUST have frequency and duration as well as modalities and interventions on therapy orders, the PT eval, once signed by the physician will meet this requirement. “PT to eval and treat” is an order that covers the evaluation only. Any visits after that must be covered with the elements I just listed. Why write it twice, when one tool can do the job? Good question!

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