Even if your practice puts the strongest policies in place to prevent compliance missteps, a payer audit is always possible.
If your practice performs regular self-audits, however, it could reduce anxiety about auditors at your door.
“Self-audits are one of the most important tasks for practices,” says Steven M. Verno, CMBSI, CHCSI, CMSCS, CEMCS, CPM-MCS, CHM, SSDD, a coding, billing, and practice management consultant in central Florida.
Performing self-audits can also help you uncover the reasons behind revenue losses, claim denials, and refund demands, Verno continues.
Slow down: Before heading full-steam for a self-audit, however, you need to know the areas where your practice is most vulnerable, and focus your self-audit on those areas.
Check out this FAQ on what areas you should focus on when preparing for self-audits.
Q: Why do payers decide to audit medical practices?
A: According to Frank Cohen, MPA, MBB, principal and senior analyst for The Frank Cohen Group in Clearwater, Fla., a payer might opt to audit your practice for several reasons: a random event that created an anomaly in your coding/billing, a benchmarking event, etc.
However, “it may be impossible to determine what triggered an audit,” Cohen said during his January 7 webinar, “Is Your Practice a Government Target? Pre-Audit Risk Analysis.” “But you must always be prepared for one,” he adds.
Q: Which coding/billing areas do payers audit most often?
A: Cohen says that payers decide to audit most frequently due to concerns in the following areas, which he defined as “The Big 5”:
1. Evaluation and management (E/M) codes (99201-99215, 99281-99284, etc.)
Best bet: Be sure to keep compliant with all payer rules on all issues — but take extra care to ensure that you have no compliance holes in Cohen’s aforementioned “Big 5” areas.
Q: What are some specific reasons payers conduct audits?
A: Within Cohen’s “Big 5” of audit hotspots, there are several specific missteps that could drive auditors to your front door. According to Cohen, practices are frequently audited for these reasons:
“As a patient, I see this so many times when I am sent a bill,” Verno says. His response to a bill without documentation, as a patient, is to request a copy of the medical record.
Claims without any documentation at all are low-hanging fruit for auditors, as they are often the easiest to prove. “With no documentation, there is no support for the bill,” reports Verno.
“I see this a lot as well,” Verno says of insufficient documentation on a practice’s claim. And quantity of documentation does not necessarily equal quality, Verno warns.
“Too many times I see volumes of words [on claims], but they don’t say anything nor do they comply with the documentation guidelines,” he says.
Incorrect coding: The provider submits documentation that does not line up with the choice of code. This often occurs when coding for E/M services.
According to Verno, some of the more frequently incorrect E/M claims are: coding for a consultation (99241-99245) rather than an outpatient office visit (99201-99215); misreporting new (99201-99205) and established (99211-99215) patient E/M codes; and coding for a high-level office visit (99204-99205; 99214-99215) when reporting a lower-level code would have been more accurate.
Best bet: Make sure your practice is as compliant as possible in the above areas; also, make sure you conduct your self-audits in the areas of most concern to your particular practice.
2. CPT® procedure code utilization by frequency
3. CPT® procedure code utilization by relative value units (RVUs)
4. Modifier utilization (modifiers 25, 57, 59 [or the new ‘X’ modifiers], etc.)
5. Time (total provider work hours your practice bills for)