Physician practices are audited all the time. It may even be
considered a routine occurrence in your office. I am certainly seeing
more clients than ever being asked to send in charts and other documents
for review. Not all audits are routine, however, and it’s important to
make sure you know who is asking for charts and the reason for audit
before shipping off requested documents.
When you receive an audit demand, look for the following red flags:
1. Have you recently expanded into new
services or items such as offering durable medical equipment (DME) or
acupuncture services?
2. Have you switched your billing company,
personnel or billing practices? This can mean a switch to a new system
or following new guidelines which you believe apply to your practice.
3. Has an employee with knowledge about your billing practices recently left? Was this departure on good terms?
4.
Has anyone questioned your supervision standards or other components of
your practice which may relate to billing and reimbursement?
5. Have you had a visit from a payer representative asking questions and requesting an “educational meeting?”
These
are only a few of the situations which can precede an audit or
investigation. If you are not already running independent audits on a
regular basis, any one of these red flags should prompt you to do so.
Once you receive the request for charts, how do you respond appropriately?
1.
Pull the requested charts, claim forms, and other documents as quickly
as possible. This will allow the practice the time needed to do its own
internal audit or to have an outside auditor review the charts. Remember
that you cannot alter the charts, but it’s helpful if you can determine
if there is a reason the charts are being requested before they are
submitted.
2. When the charts are submitted, include a cover
letter which shares any findings from your own internal audit, the steps
that have been taken to correct the problem and, if appropriate,
reimbursement for the claims related to the requested charts. These
steps should become part of the practice’s compliance plan related to
billing.
3. Consider consulting with a billing expert for the
audit. This is especially important if you handle your own internal
billing and use self-trained billers. You cannot rely on the same person
who oversees your day-to-day billing to complete an audit of their own
work.
4. Depending on the size and type of audit, consider having
the independently-retained auditor hired through legal counsel. If there
are findings that present legal concerns, the legal privilege may
provide some additional protection.
5. Remember that anyone you
hire to review your charts will be accessing patient health information.
All appropriate HIPAA safeguards are required.
As always, talking
with legal counsel is a good step. Audits can be the start of something
bigger depending on who is making the request. Zone Program Integrity
Contractor (ZPIC) audits, charts requested through a subpoena, and other
similar scenarios are indicators that legal advice is absolutely
required.
Sometimes physicians become overconfident that they are
doing everything correctly in their practice. Reading books on billing
and sending your staff to an occasional coding class do not mean you are
handling things appropriately. A client of mine who is under
investigation swears he has done everything right — he has read every
book, he sends his biller to coding classes, and uses a billing company
with expertise. His practice brings in an enormous amount of revenue and
he is highly respected. There is no question he is a fine physician.
Our
external audit of the requested charts have so far revealed
insufficient documentation and improper coding While the findings
reflect a lack of knowledge, as opposed to intentional fraud, it’s
unknown how the pattern of billing will be labeled by this
investigation. The repercussion could be tremendous for the physician,
his practice, and his family. What should he have done differently? What
should you do to prevent this from happening to you?
One final
piece of advice: Spend the time and the money NOW to review your practice’s billing, coding, and compliance. This is by far the smarter,
and less expensive, alternative to that non-routine audit which may be
just around the corner.
Source from Physicians Practice
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