Healthcare attorneys and compliance officers spend hours manually drafting chart audit protocols, cross-referencing regulatory requirements, and creating comprehensive checklists for documentation and coding reviews. The process requires deep knowledge of CPT/ICD-10 coding standards, billing regulations, and clinical documentation requirements, making it time-consuming and prone to omissions.
Healthcare organizations face mounting pressure to conduct thorough chart audits that satisfy regulatory requirements while demonstrating good faith compliance efforts. Creating comprehensive audit protocols manually requires extensive time from compliance teams, legal counsel, and clinical staff, often taking days to develop documentation that meets OIG standards, Medicare requirements, and payer expectations.
CaseMark automates the creation of comprehensive, defensible chart audit protocols tailored to your specific regulatory framework and risk areas. Generate complete audit documentation including methodology, review criteria, findings templates, and corrective action frameworks in minutes instead of days, ensuring regulatory compliance while freeing your team to focus on conducting audits and implementing improvements.
This workflow is applicable across multiple practice areas and use cases
Chart audit protocols are critical during healthcare M&A due diligence to assess coding compliance, identify billing risks, and evaluate potential regulatory liabilities in target medical practices or hospitals.
Buyers in healthcare M&A transactions require comprehensive chart audits to uncover compliance issues, quantify potential Medicare/Medicaid overpayment exposure, and assess the quality of clinical documentation before closing.
Healthcare organizations with government contracts (Medicare/Medicaid) need chart audit protocols to demonstrate compliance with federal billing and documentation requirements during government audits.
Government contractors in healthcare must maintain rigorous audit protocols to satisfy CMS requirements, respond to RAC audits, and prove compliance with federal healthcare program regulations.
Chart audit protocols are essential in healthcare fraud litigation and medical billing disputes to establish documentation standards and identify compliance violations.
Commercial litigation involving healthcare providers, insurers, or billing disputes requires systematic medical record audits to prove or defend against claims of improper billing, fraud, or breach of contract.
Defense attorneys in healthcare fraud prosecutions use chart audit protocols to systematically review medical records and demonstrate proper documentation standards or identify weaknesses in government allegations.
Criminal healthcare fraud cases require detailed chart audits to defend against allegations of upcoding, unbundling, or medically unnecessary services by establishing compliant documentation practices.
The protocol addresses Medicare Conditions of Participation, OIG Compliance Program Guidance, RAC audit preparedness, federal sentencing guidelines, and payer contract obligations. It creates documentation that demonstrates compliance with the duty to monitor and audit as required under federal healthcare regulations. The framework is adaptable to state licensing requirements and specific organizational risk profiles.
The protocol creates a defensible audit trail that demonstrates systematic, good faith compliance efforts to regulatory authorities and investigators. It includes proper sampling methodology, transparent review criteria, quantified findings with appropriate categorization, and documented corrective actions. This comprehensive documentation can support privilege considerations when conducted under attorney direction while showing proactive compliance monitoring that may mitigate penalties in enforcement actions.
Yes, the protocol includes specific analysis frameworks for determining whether identified overpayments meet mandatory refund thresholds under the 60-day rule. It provides guidance on quantifying overpayments through statistical extrapolation, evaluating whether error patterns suggest systematic issues requiring disclosure, and documenting the steps necessary to refund overpayments while minimizing penalties. The protocol helps organizations make informed decisions about voluntary self-disclosure to demonstrate good faith compliance.
This protocol is designed for hospitals, medical practices, ambulatory surgery centers, and other healthcare providers subject to Medicare billing requirements and OIG compliance guidance. It's applicable to organizations conducting routine periodic assessments, targeted reviews responding to identified risks, or proactive audits following regulatory updates. The framework scales from small practices to large health systems and can be customized for specific service lines or risk areas.
The protocol establishes comprehensive review criteria that evaluate alignment between clinical documentation and reported CPT, HCPCS, and ICD codes. It assesses whether documentation supports billed service levels, medical necessity, modifier usage, and NCCI compliance. The framework distinguishes between technical documentation deficiencies and substantive coding errors, categorizes findings by financial and regulatory risk, and provides specific remediation strategies including provider education, workflow improvements, and system modifications.