Medicare Compliance & Reimbursement

Although an audit is a routine function that the OIG and payers must perform, it can strike fear into the hearts of medical practices everywhere. If you get word that your practice will soon be audited, follow these tips to help put your best foot forward.

Don't wait until the OIG or your MAC alerts you that an audit is imminent before you get a handle on where you stand from a compliance standpoint, says Patricia A Trites, MPA, CHBC, CPC, CEMC, CHCC, CHCO, CHP, CMP(H), CHAP, vice president of Healthcare Compliance Resources, LLC in Sherman, Tex.

"Internal audits are the best way to prepare for an external audit," Trites advises. "This process allows the practice to find errors and patterns of errors before someone else does."

"The second step to internal auditing is just as important -- education," Trites says. "If the providers don't know or don't understand why something is incorrect or why another way is better, then the errors are never corrected going forward."

Once you know that an auditor will be paying you a visit, sit down with your staffers to fill them in on the details. Although it may be tempting to keep the audit a secret so you don't make anyone nervous, it's in your best interest to keep everyone apprised of the situation.

"I really do believe it is important that affected staff is trained before the auditor comes onsite or even if records are being requested for audit through the mail," Trites advises. "Staff that knows what is going on are less likely to start rumors or listen to rumors."

Let staffers know that they should be polite and respectful to the auditor, "and to always, always, always tell the truth," Trites says. "There are so many types of audits that could be undertaken within a healthcare practice today it is hard to cover all the bases of what-ifs, but I suggest that staff understand that an audit does not mean that the organization or any of the providers have done anything wrong."

Keep in mind: Many audits are conducted to determine if the carriers/MACs are doing their jobs correctly. Does that mean if they find something the practice has done incorrectly, they will get a pass? "No," Trites says. "That is why it is important that each person understand their responsibility and liability in performing services, documenting those services, and then billing the services to the various payers."

If your practice has never performed a self-audit, but you get word that you'll soon be audited, Trites offers these four tips:

1. Don't panic! Auditors aren't necessarily on a witch-hunt.

2. Pull all encounters that have been selected for audit with all of the accompanying documentation.

3. If you believe there may be a problem with your claims or how they were billed, contact an attorney to help you through the audit process. If not, move to step 4.

4. Perform an internal audit of the claims and if necessary, hire an external auditor to also review the claims. "It's best to let the practice attorney engage the external auditor toprotect the reports under attorney work product," Trites says.

What this means: If the attorney hires the consultant,the work performed during the audit falls under the attorney- client privilege, says Michael F. Schaff, Esq., with Wilentz, Goldman and Spitzer in Woodbridge, N.J. 5. If there is a problem, do not alter documentation, alter billing records, destroy records, or in any other way compromise the information, Trites says.