“We have worked with HMR on several major projects over the past 19 years — we value their knowledge, advice and sense of partnership with our group. We recently launched our AuditGuard® program to help prepare our 400+ physicians against ongoing recovery threats and to significantly improve our financial performance. We know HMR well — they consistently deliver what they promise.”


Audits—be they RAC, MIC, MAC, or private payer—pose a serious threat to your practice, your finances, and your reputation. You may not yet realize it, but you are already in the crosshairs of these federally empowered auditing initiatives, which are set up to take back reimbursement from you and your organization. In the past, RACs have been comparatively unaggressive in pursuing audits of physicians. That dynamic, however, started to change in September 2012 when CMS mandated that one RAC region, Region C managed by Connelly, pursue physician evaluation and management audits using extrapolation methodology to compute repayment amounts. Since that time we have seen a substantial increase in RAC activity in both hospital operated and physician owned practices. As evidence thereof, through December 2012, RAC recoveries from providers had increased by 2,939% over 2010 results. CERT audit activity has always been substantial in physician practices, but has also increased markedly in the past eighteen months.

RAC Overpayment

These aggressive audit programs are not comprised of one-time events. They are ongoing, progressively intrusive programs with the sole purpose of recovering reimbursement from health care providers. The unfortunate fact is you will contend with these auditors year-in and year-out for the foreseeable future. Protect your organization, like hundreds of others already have, with AuditGuard®.


How do the Recovery Audit Contractors (RACs) and others pick their targets?

If you are a Medicare provider, you will be targeted for RAC, MAC and CERT audits. If you are a Medicaid provider, you will be targeted for audits by a MIC. Unfortunately, these are not onetime events and all providers will be audited on an ongoing basis. The audit programs have been federally legislated into permanence and will become progressively more intense as the auditors increase their resources and healthcare expertise.

Other than the simple fact that you are a Medicare and/or Medicaid provider, many reimbursement audits are triggered by coding, billing and utilization anomalies. From the RAC/MIC/MAC's perspective, it is fertile territory, as physician coding error rates alone average 58%. Physician practices were put even more at risk In September 2012 when CMS mandated that one RAC region, Connelly's Region C, begin to audit physician evaluation and management encounters using extrapolation methodology to compute repayment amounts. RAC audits can take two possible iterations. They can be a focused medical review, which is a request for specific charts, or they can be done through sophisticated data mining protocols. It is the data mining protocols that are particularly insidious for physician practices. These protocols allow RACs to audit providers remotely without ever reviewing a medical record, extrapolate error rates for many services, assess repayment amounts and penalties, and send demand letters for repayment. When you receive a demand letter you have thirty days to pay the amount demanded or you must enter into the five level appellate process.

What are my options regarding defending my practice against RAC/MIC/MAC audits?

First and foremost, the best offense is a great defense. You must act immediately to identify your areas of vulnerability—the anomalies in your practice that will cause your practice to be targeted and closely examined by RAC/MIC/MAC/CERT auditors. You must change and improve the behaviors, coding and billing patterns, and skill sets of staff and providers; you must become a precise, fully compliant, documenting, coding and billing team. If you can accomplish this you will have taken the most important defensive step possible—you will no longer be an attractive target and they will likely move on to more lucrative opportunities. However, the vast majority of physician practices, whether hospital operated or physician owned, do not have the internal resources to successfully achieve the aforementioned elimination of vulnerabilities.

So when audits occur, you must be prepared to defend yourself with the staff you presently employ. Your staff, however, may or may not have the expertise to mount an effective defense, and they may not be facile enough with the process to effectively manage a successful audit defense. Many practices turn to their lawyers, but this is a very expensive proposition that often entails not just substantial legal fees but also large consulting fees for shadow audits and professional advice that attorneys alone cannot provide. The fact that RAC/MIC/MAC/CERT audits are an ongoing process makes the utilization of an attorney for audit defense an unrealistic option for most organizations, financially.

Your best defensive option is to become part of AuditGuard®. Your professional AuditGuard® team will work closely with your providers and staff to eliminate all areas of audit vulnerability, thus minimizing the chance of RAC/MIC/MAC/CERT audits occurring. But if the worse happens, your AuditGuard® team will provide the defense of your practice each time a RAC/MIC/MAC/CERT audit occurs. Your AuditGuard® team will manage the entire audit process for you, from initial audit response through the appellate process.

I have read several articles but have yet to be contacted by my RAC. Do I really need your service?

It is inarguable that RACs have been comparatively unaggressive in auditing physician practices. However, in September 2012 CMS mandated that one RAC region, Connelly, begin to audit physician evaluation and management encounters using extrapolation methodology to compute repayment amounts. Since that time, we have seen a substantial increase in physician audits in the southeast and the evaluation and management mandate will eventually encompass the entire country.  So, do not relax or be lulled into complacency and inaction—your times are coming. These are not potentialities—these are federally legislated, permanent programs that have already been created and are targeting your organization. And remember, these are not one-time events. The audits will be ongoing and will gain in intensity as the programs mature. It is imperative to face the reality of the situation; the legislation that created these never-ending audit programs specifically included physicians and you will, unfortunately, be dealing with these RAC/MIC/MAC/CERT auditors for years to come. We see no reasonable alternative but to become a part of AuditGuard®, eliminate your audit vulnerabilities, mitigate the chance of an audit occurring, and minimize exposure to repayments and penalties, while realizing maximum legitimate reimbursement and achieving unparalleled levels of compliance.

When will my practice be audited?

There is no way of determining when they will be contacting you—but be assured RAC/MIC/MAC/CERT will target your practice. What we do know is that to date (January 2013) all RAC audits have sampled
encounters within six months of the audit date. Since future behaviors can usually be predicted by assessing the past, you can see why we stress the need to get prepared immediately. If you can identify and eliminate your audit vulnerabilities tomorrow, in six months you would have very little exposure.

Why should I align with HMR and AuditGuard®?

We have over twenty years of experience in protecting hospital operated and physician owned practices from compliance problems, billing issues and payor audits. To date, we have audited, trained and protected more than 4,000 physicians and are the go to company for hundreds of hospitals, physician practices and healthcare law firms. Our deeply experienced, nationally certified staff exclusively serves the needs of hospital and physician owned practices and has the proven ability to effectively change staff and provider behaviors. Not only will we mitigate your audit exposure, we will improve your reimbursement and have a positive effect on your bottom line operating results. After one year of working with their AuditGuard® team, our typical client reports an average 5% to 7% increase in annual reimbursement. Our service is made available to you on a subscription basis and is affordable to practices of virtually any size. We work with multi-hospital integrated health systems, single provider practices and virtually everyone in between. We have the proven ability to reduce billing and coding error rates from an average of 58% to <10% within the first six months. When you do get audited, we leap into action to defend you and will manage the appellate process should it be necessary. AuditGuard® is an absolutely unique service, it is all we do and we do it exceptionally well.

How do I get started?

Call us at 1.804.327.9993, email us at info@audit-guard.com or use the contact page. One of our AuditGuard® specialists will discuss your organization’s needs, listen to your concerns, and we will apply the optimum AuditGuard® level of service to your situation.