Payer audits are on the rise, including Medicare, Medicaid, and private payers. Regardless of whether violations are found, audits are time consuming, disruptive, and expensive. The sophistication of claims processing edits, provider profiling and questionable billing patterns all contribute to identification of unusual coding and billing. When documentation does not support the codes billed, providers are often liable for recovery of funds and possible penalties. This presentation will discuss situations that cause payers to scrutinize providers for possible audit activity. Avoid costly disruptions and revenue loss by understanding how payers identify areas of concern and initiate potential audit activity & provider scrutiny.Areas CoveredPayer system editsDiagnosis vs procedure Specialty and Evaluation & ManagementMinimal coding variationsUnrealistic number of unitsDiscrepancies in written chart & EMRDiscrepancies: hospital, physician, anesthesiaLesion sizeFailure to state timeRepeat billing; no resolution of errorsInappropriate modifier useWho Should AttendBillers, coders, revenue cycle staff, denial management staff, clinical documentation staff, physicians, midlevel providers, and risk management staff.Why Should You AttendWho Initiates Audits? Protect Your Revenue!Audits may be initiated by payers, State Medical or Health Boards, whistleblowers, patients, and other parties. Claims are fair game for audit activity upon claim submission. Heavy reliance on system prompts without adequate training often leads to questionable patterns that do not meet acceptable reporting. Learn what payers expect and reduce costly rejections and denials.Topic BackgroundMany providers have seen an increase in denials, requests for records, rejections, and other activities that create revenue delays and possible revenue loss. Learn areas that are likely to initiate these negative outcomes and improve the protection of your reimbursements.