Medicare Audit

Medicare is taking aggressive steps to enforce evidence-based coverage policies, and curb potential fraud and abuse. The Medicare RAC audits, Medicare ZPIC audits, PSC audits and MEDIC audits represent a significant and immediate financial risk for any health plan provider. Given the complex process for appeals and stringent penalty clauses, health plan providers should prepare themselves to handle the entire Medicare audit process from a position of strength and confidence.

Medicare RAC audits, administered at the Federal level by the CMS, focus primarily on identifying overpayments, while ZPICs are responsible for preventing, detecting, and deterring Medicare fraud by reviewing all claim types. With RAC auditors being incentivized with a percentage of the overpayments identified, it becomes even more important for health plan providers to be one step ahead.

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MetricStream Medicare Audit Software Solution

MetricStream offers a comprehensive solution to not only automate, streamline, and integrate the preparation for Medicare audits, but also promote a more proactive approach to the process. From fulfilling record requests, to ensuring timely submissions, to making determinations and appeals, the solution enables organizations to manage all aspects of Medicare audit requirements on a single, centralized platform.

With the MetricStream solution, health plan providers are well able to manage the different steps of creating, compiling and reviewing claims, collaborating with different stakeholders, and managing appeals in a smooth and efficient manner. The automatic routing of information to various stakeholders such as the Revenue Recovery department and the Appeals Coordinator is made possible with the help of the solution's in-built workflows. The entire appeals process is simplified by automating the task of preparing, reviewing, approving, and finalizing appeals.

Advanced capabilities such as built-in status tracking and reporting, integrated document management, remediation action workflows, and auto generation of letters allow organizations to implement industry best practices for regular self-assessments and internal audits. The solution empowers organizations to stay ahead of RAC audit requirements, while mitigating the risk of losing legitimate earnings.

Centralized dashboards enhance visibility into the process, enabling managers to easily track the Medicare audit status. Powerful reporting capabilities provide trends and graphical charts based on a wide range of variables, including the service that is being audited, the physician associated with the service, and diagnosis codes. By tracking the audit patterns thus, the solution enables health plan providers to gain a complete view of the appeals at every stage.

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