Why Is My Medical Practice Being Audited?

Receiving notice of an audit can be stressful, but with the right processes in place, it doesn’t have to be. Learn the different types, what to expect from each, and how to prepare.

Who Can Audit My Practice?

Audits can come from many different sources, including government programs, payers, and regulatory bodies. Maintaining compliance with contracted payers, government payers, and quality and environment of care initiatives can be a big job. When thinking about potential audits that can come your way, it is easier to think of them as fitting into two large buckets: Cost and Quality. At the most basic level, auditors are trying to determine if the care that is being provided is adhering to quality standards, and is as cost-efficient as possible.

Virtually any payment programs that providers participate in are subject to audit. Enrolling to accept private insurance plans, Medicare, or Medicaid means that those payers will be analyzing payment patterns, medical necessity of services, and determining correct coverage.

Can I Prevent Audits?

The short answer is – sometimes. A proactive approach to staying in compliance with payers, contractors, and accrediting bodies is a full-time job, but a worthwhile one that also makes financial sense. Anticipating potential areas of audit risk is a good step to possibly prevent an audit, and to also be better prepared if one occurs.

All payers, including the government, have specific guidelines about what types of care, services, and procedures are covered. Adhering to the requirements of National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs), and keeping up with changes is essential to prevent claims denials and outliers that may lead to later audits.

Private payers and Medicare Advantage Plans will have specific contract requirements that are agreed upon as part of the patient’s coverage. Adhering to those requirements, including any pre-authorization requirements, is essential.

Another way to prevent excessive audits is to stay current with new legislation, new NCD and LCD changes, and hot topics for audits that year. CMS provides coverage email updates via listservs, and Medicare contracts, such as regional Medicare Administrative Contractors (MAC) organization provide education in the form of webinars and updated information. Many third parties also provide education, such as professional organizations, consultants, and vendors.

CMS and private payers also provide useful tools in the form of clinician newsletters and documentation checklists. By integrating these into applicable clinic processes, adherence to NCD and LCD requirements is much easier, resulting in cleaner claims and reducing the likelihood of secondary review.

How Do I Prepare?

To stay on top of current trends and requirements, organizations need to designate staff that regularly communicate with the assigned MAC as needed, including attending education sessions and then disseminating information about new standards and regulations.

Each organization should perform some type of compliance risk assessment each year to internally assess which services may be subject to audit. There are many templates and tools available to assist organizations in conducting a formal compliance risk assessment. When deciding on the right methodology to follow, a good rule of thumb is to make sure that risk assessment includes these components: legal impact, financial impact, business impact, and reputational impact.

A good risk assessment and subsequent action plan should involve input from a multidisciplinary team, and then assign accountability for each identified risk. Continuous monitoring and updating of high-risk areas is important to ensure continuous improvement.

I’m being Audited – Now What?

Typically, an audit occurs after a payer has identified a potential issue after doing a further review of claims. Receiving many Additional Documentation Request (ADR) letters requesting supporting claim information, and denials can be a good indicator that an audit may be forthcoming.

Service Specific Post-Payment Reviews and/or Pre-Payment Reviews are then used to determine the extent of potential problem areas and to monitor corrective actions implemented.

When responding to an audit, it is important to provide a timely and complete response. Pay special attention to the complete request for medical records, and make sure to provide each item listed for the dates of service listed. Factor in transmittal time back to the auditing party, whether the information is sent electronically or by mail. If you have questions about the request letter, contact the auditing party early in the process. Keep accurate records of everything that was sent, dates transmitted, and dates of communications, and engage your team to begin work on any corrective action plans that may be anticipated.

Providing complete and timely medical records for all types of requests – audits, legal actions, collaboration of care, and patient requests can get overwhelming – and costly! Delays and missing records can have dire consequences.

RecordQuest is a leading release of information company that provides support, compliance knowledge, and superior technology to help navigate the ever-changing healthcare landscape. If your medical records processes need life support, contact us for a web demonstration and more information.




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