Medicare Advantage Audits

Many of our Skilled Nursing Home clients undergo Medicare Advantage audits throughout the year. Health plans are determined to not pay a single dollar more than they must, and recoupment requests are becoming increasingly common. If you get audited, you will get a request for medical records and other documentation. Do not ignore or back burner these requests.

Our experience tells us the less you respond, the more audits you may get.

Here's what we recommend:

Sign up for portal & email notification of audits instead of relying on snail mail.

A paper letter could wind up on the wrong desk and you're already behind the 8-ball. Be on the lookout, and make sure you get electronic notifications whenever possible.

Get your care team engaged immediately

Track your claims and know your deadlines. Form a collaborative partnership between nursing staff and therapy staff when reviewing documentation. With real money on the line, you want your best talent submitting your responses. Be sure to have sign-off by all parties before sending in records.

But this is just the beginning

After you submit your responses, then comes the Post Payment Review. Things we have seen in Post Payment Review include:

• Missed sections on the MDS

• Omitting therapy documentation

• Services need to be justified with daily nursing notes

• Your claim has been overpaid so please submit a refund. If you disagree, please write back. If we don't receive a response within 30 days, we will deduct it automatically