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Medicare Compliance & Reimbursement

AUDITS:

Get To The Bottom Of Audits--And Come Out On Top

Published on Wed Apr 19, 2006

3 red flags could make providers' claims suspicious.

Why do bad audits happen to good physicians?

Physicians aren't wasting their time when they ask why their carriers have decided to put their evaluation and management claims on prepayment audits. In fact, this may help providers get off prepayment review more quickly, say experts.

Providers should ask themselves, "Why was the physician put under a prepayment audit in the first place? What was the red flag? Was she billing too many high-level codes? Too many consults?" advises Suzan Hvizdash, medical auditor with University of Pittsburgh Physicians department of surgery.

If the provider can't answer those questions by running reports and going through charts, then the provider should schedule a meeting with the carrier, Hvizdash adds. Some carriers may be able to provide medical offices with some valuable insights into the reasons for their audits.

Each Medicare carrier may have its own guidelines for which claims require a prepayment review, notes consultant Cindy Parman with Coding Strategies in Powder Springs, GA. Usually providers will find themselves on prepayment review if their claims appear to be "outliers" because they bill more visits or higher-level visits than average. NHIC has a good summary of its policies online at www.medicarenhic.com/cal_prov/med_review.shtml.

Providers may not be able to tell in advance whether their claims will spark an audit by looking at each individual claim, notes Parman. But they might get a clue as to whether they're targets by running a report to look at their E/M "bell curve" and comparing this to the national data that the Centers for Medicare & Medicaid Services publishes on its Web site.

Watch For 3 Red Flags

There are some red flags bound to attract an auditor's attention--providers need to make sure their charts avoid these pitfalls.

1. A laundry list of diagnoses won't wash. If most of the diagnoses on a claim don't seem relevant to the E/M visit, then the carrier will suspect the provider has upcoded, says Tammy Young, an independent coder/auditor in New Jersey.

2. Detailed or comprehensive exams for a simple problem. A patient with a runny nose and cough doesn't need a neurological exam, psychiatric evaluation and gastrointestinal workup, notes Young.

3. Worksheets or EHRs. If the doctor checks off many boxes showing that various body systems are normal, but he doesn't expand on that finding at all, it may look suspicious to auditors, says Young. Billers must make sure their doctor checks off only the boxes for areas he actually examined or for which he performs review of systems.

Billers need to pay attention to other factors that may increase the E/M level, too. When a physician performs a history on a patient, she is looking for other conditions that may play into the main diagnosis, says Barbara Cobuzzi, president of CRN Healthcare Solutions in Tinton Falls, NJ.

For example, if a patient comes in with an upper respiratory infection, that's probably a pretty simple problem, explains Cobuzzi. But suppose a patient comes in with a URI and has a history of URI, is immune compromised or has diabetes or cystic fibrosis. All of a sudden, the URI is no longer straightforward, she says. Providers must look for these sorts of factors in their charts that may suggest they've upcoded them when they've actually coded them correctly.

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