Certified Risk Adjustment Coder (CRC)

Why is it often difficult for companies to follow CMS directives regarding deletion of conditions in retrospective audits?

1. There is a potential loss of revenue

2. Billing compliance issues may come to light

3. All companies follow CMS directives

4. I and II

The correct answer is: I and II

Retrospective audits can create challenges for companies in adhering to the Centers for Medicare & Medicaid Services (CMS) directives regarding the deletion of conditions due to a couple of significant factors. Firstly, the potential loss of revenue is a critical element. When conditions are deleted during retrospective audits, it can directly impact the reimbursement rates that a company receives. This loss of revenue can be a deterrent to fully complying with the directives because organizations are often focused on maintaining financial stability and operational funding. Secondly, auditing processes can reveal billing compliance issues. If errors or discrepancies are uncovered through the audit, it may lead to further investigations and possible penalties. Companies may hesitate to take action that could expose them to penalties or backlash from regulatory bodies concerning billing practices. Together, these reasons underscore why adherence to CMS directives can be particularly challenging during retrospective audits. The combined risks of revenue loss and compliance issues often result in complex decision-making processes for healthcare organizations.