Medicare Compliance & Reimbursement

Find Out These 3 Things First

Before you start the conversation about your audit, you need to know the answers to some basic questions.

First and foremost: Has the provider seen the results? “That’s the first thing I ask a provider when I’m communicating results to them,” Clements said.

Note that a lot of times, external auditors send audits to management rather than to the providers, so providers may not have even received the audit findings, let alone had a chance to review them, she said.

“Always ask, because if they haven’t looked at the results, you kind of have to start from scratch as you’re communicating that information,” she said.

Making sure the provider or coder has seen the results before a conversation can be helpful, especially if the results aren’t good, underscored Jaci Kipreos, CPC, CPMA, CDEO, CEMC, CRC, COC, Approved Instructor/AAPC, in the same presentation. If they’re seeing the results for the first time as you present them, you don’t have the buffer of time and space because they’re processing the results while you’re there.

If you can’t confirm with the provider that they’ve seen the results ahead of time, make sure you go into the conversation with that in mind, Kipreos warned.

Second: It’s also important to know ahead of time how the organization approaches final determinations, because you’ll need to know their policy regarding disagreements.

For example, if the auditor thinks that the coding of an encounter isn’t supported by the documentation, but the provider believes it is, it’s important to know who will make the ultimate decision. The auditor’s opinion may be lower risk, but if the provider is willing to get on the phone during a formal audit and explain their reasoning, then it may be OK to let it stand, Clements explained.

Third: When you meet with a provider, it’s also crucial to make sure you know whether you’re meeting with an individual or with multiple providers. Some organizations may have confidentiality measures in place that wouldn’t allow an auditor to discuss individual results in a group setting. In that case, you can phrase your report findings in terms of trends seen for the entire group and frame them as opportunities for improvement, Clements said.

Similarly, you need to know how you’re presenting the information you or the auditor found, like in a formal presentation or as a more casual conversation. If the audit is internal, and the auditor is already a member of staff, then there may already be some rapport there, which could affect the way you present the findings.

Prepare for Potential Trouble Via Backups

No one likes to feel belittled, and many people also have trouble withstanding being challenged, especially if they perceive a differing opinion as coming from someone with less knowledge. Of course, auditors also have specialty knowledge, and some providers or other stakeholders can be hostile when hearing audit results, especially if the results aren’t favorable, Clements and Kipreos warned.

If you’re going into a situation where you’re nervous about the reaction of whoever is receiving the results, take some precautions. In such a situation, “the biggest thing you can do is make sure you’re not going in alone,” Clements said. For example, you may want to see if your manager can be present for the conversation.

If you do find yourself in a conversation that becomes uncomfortable, Clements recommended politely removing yourself and then connecting with your immediate supervisor, allowing them to handle the situation.

If you’re meeting virtually, you can suggest scheduling another call after they’ve gone through all the audit results and added comments and concerns — and you’ve had time to review their marginalia, Kipreos suggested.

Make sure you keep track of troublesome providers, if you encounter any, Clements said. That way you know how to prepare for any future audit reviews.

Bring Your Homework With You

Take advantage of available resources, too, when preparing for a meeting. You have to go in prepared to answer questions — and also have the ability to say you don’t know the answer to a question but that you will pursue some research and circle back to provide the most valid answer, Clements said.

“I always have the guidelines ready to pull up on the screen, or, if we’re in person, I bring them with me,” Kipreos said. This can be helpful when talking about incident-to or modifier guidelines, for example, and provide a fact-based jumping off point, in terms of education or resolving any differences in opinion.

And remember, simply stating “I hear your concerns” or “I understand your frustration” can go a long way in dialing down emotions or reactions, Kipreos said.

It’s helpful to frame an audit as an opportunity for education — and you should take advantage of every opportunity, Clements and Kipreos said. When you’re presenting the results, categorize them as physician opportunities or system opportunities, and summarize any trends you find accordingly.

Mention tiny tweaks they can make as improvements, too. Even if the providers are doing a great job documenting an encounter with a new patient, you may have a tip to offer that encompasses work they’re already doing but not actually reporting.

“One thing I’m telling all providers now, is when you have a new patient and you’re coding level on medical decision making, don’t tell me you didn’t review notes from other people. You know you didn’t document that, but you know you reviewed something else. This is working toward your data point,” Kipreos said.

Ultimately, audits are an opportunity for education for providers. Framing them accordingly, being confident in the auditor’s knowledge, and seeing issues as opportunities to educate or improve practices are key to helping conversations about audit results go smoothly.