Pre-payments and Post-payment Audits

The AAFP advocates that pre-payment and post-payment audits should be infrequent, highly selective, supported by analysis showing definite abuse of the code in question, and demonstrate clear reasoning why the problem is not remediable by less onerous mechanisms. In lieu of broad pre-payment or post-payment audits, payers should use focused medical review of outliers based on reviews of patterns of services, using an independent medical peer review process, where physicians practicing in the same specialty, review their peers. The AAFP believes that broad use of pre-payment and post-payment audits is a significant business disruption for the physician office and creates an inappropriate culture of mistrust. (2014 COD)