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Medical Coding News Archives

Nothing is certain except death and taxes…and auditing!

 
January 18, 2017:

Back in 1789, Benjamin Franklin remarked that, “In this world nothing can be said to be certain, except death and taxes.” But, in the 21st century, there is another certainty – especially for providers of health care – and that is the use of auditing by payers and providers to examine the validity of medical claims. What makes auditing a certainty is the growth of health care expenditures in the last 25 years, and the few ways in which those costs can be controlled.

By most estimates, health care costs will consume 20 percent of the Gross Domestic Product (GDP) in 2017, or very soon thereafter. At this historically high level, expenditures for health care lower wages and make U.S. companies less competitive internationally. Simply put, at 20 percent of GDP, health care crowds out other sectors of the economy.

Sure, cutting payments to hospitals and physicians can yield immediate and significant results, but plans for draconian cuts will be opposed by the members of Congress representing health care workers. A much more equitable approach to controlling costs is to eliminate unnecessary “waste” that drives up health care costs. But, eliminating waste means examining claims for medical necessity and administrative compliance, which includes a wide range of edit points that plague provider claims today. In short, auditing isn’t going away – especially in an environment where costs of care are a threat to the U.S. economy.

Waste in the U.S. health care system

How much can auditing cut from the U.S. health care system? One recent estimate* says waste makes up $1.2 trillion, or about 37 percent of total U.S. health care costs – nearly all of which can be addressed through processes that involve review of medical claims.

For information about how to audit – and survive audits – check out the 2017 Auditors’ Desk Reference.

*Journal of the American Medical Association, March 14, 2012, Eliminating Waste in US Health Care.

 

 
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