In addition to the Corporate and Financial Investigation Department?s (CFID) role in preventing fraudulent practices against AmeriHealth, CFID is also tasked with conducting audits of facility, professional, and ancillary service providers. CFID?s goal in these audits is to control medical costs and prevent increases in member premiums by ensuring that all claims submitted to AmeriHealth have been coded and billed correctly and have been paid in accordance with our provider agreements. The audit staff is comprised of nurses and coding professionals, as well as experienced claims data analysts, who collaborate with AmeriHealth medical directors and reimbursement specialists to identify and correct questionable trends and patterns in coding and billing.

Facility provider audits:

Credit balance audits correct overpayments that can adversely affect the balance sheets of both AmeriHealth and its hospital providers. Credit balance audits are conducted onsite by CFID auditors or HIPAA-compliant vendors selected for productivity and reliability. DRG audits focus on the correct coding of documented medical information by analysis of medical records for inpatient claims. Based on the recommendations of the Office of the Inspector General and the Centers for Medicare & Medicaid Services, AmeriHealth auditors select a number of high-risk inpatient claims to review each year for almost every provider of inpatient care. Outpatient fee schedule audits select claims for review based on either government edits (e.g., National Correct Coding Initiative [NCCI] edits, Medically Unlikely Edits [MUEs]) or on those procedure codes that have been identified as frequently miscoded and incorrectly billed, such as surgical debridement versus wound care, or cosmetic procedures. AmeriHealth medical policy audits are conducted to ensure that facilities are aware of, and follow, AmeriHealth medical and claim payment policies as they pertain to our members. Likewise, CFID conducts audits to make sure the rules and guidelines outlined in the Hospital Manual for Participating Hospitals, Ancillary Facilities, and Ancillary Providers are applied correctly when billing AmeriHealth. Never Event audits are audits of claims containing code information about Serious Reportable Adverse Events (also known as "Never Events"). These audits fulfill government reporting requirements and ensure that our members are receiving quality care in a safe medical environment. Facility audits may change and expand as new issues are identified that affect patient care. CFID can identify new issues when needed using specially designed data-mining software.

Professional provider audits:

Inpatient and outpatient evaluation and management (E&M) services audits ensure that appropriate levels are billed and paid, including consultation codes and the use of modifiers 24 and 25 with E&M claim submissions. Office site-of-service audits ensure that services receiving a site-of-service differential were rendered and billed in the office where the service took place. Modifier 25 audits look at E&M codes billed with modifier 25 on the same day as preventive medicine codes were billed to ensure that the documentation that supports the E&M service was for a significant and separately identifiable service from the preventive medicine service. New patient E&M code audits verify that a patient has not received a new patient E&M service, within the past three years, from any physician of the same specialty in the group. If the patient has, a follow-up E&M would need to be billed. Electronic health record audits ensure that medical records do not contain inaccurate information that may indicate that the provider documented more work than he/she actually did or needed to do. Single- versus multiple-unit audits ensure that the correct units are billed as defined for CPT^? codes. High-dollar medications audits focus on high-dollar medications that are administered in a physician's office to ensure the accuracy of claims billed. Duplicate billing audits ensure that duplicate claims are denied appropriately. Split billing audits look at claims for the same member, from the same provider, for the same date of service and visit.

Ancillary provider audits:

High-dollar medications audits review high-dollar medications administered in the home setting to assure the accuracy of claims billed. Durable medical equipment audits ensure that claims accurately reflect services rendered. Medication compounding audits ensure that necessary and appropriate compounding and billing are done only when commercially prepared mixtures are unavailable. Health care fraud is a violation of state and federal law. An easy-to-use process exists for reporting any suspected fraud, waste, or abuse. If you are suspicious of any health care-related activity, please visit the Anti-Fraud page on our website or call our toll-free Corporate Compliance and Fraud Hotline at 1-866-282-2707. These tips can lead to audits, fraud investigations, or both, that may result in monetary recoveries that help keep health care costs down.