Practice Management Alert

And never forget to ask this simple question up front.

Auditing your organization isn’t important just because it’s part of the compliance plan. Auditing is important because it’s the only way to know whether you’re doing anything correctly, said Jaci Kipreos, CPC, CPMA, CDEO, CEMC, CRC, COC, CPCI, the president/owner of Practice Integrity LLC, in AAPC’s AUDITCON in November 2021.

So, first thing’s first: Figure out what you want to look at.

Shift Your Focus to These Categories

“The reason we audit, even if it’s monitoring, is you never know you’re ‘to the good’ until you look. You can guess that you’re to the good. Never say ‘I don’t need an audit because we’re getting paid.’ That’s not a reason not to audit; if you’re getting paid, that’s great, but that doesn’t mean your notes can support what you got paid for,” she said.

“That’s the best reason to even start internally, just a sample of a few claims,” she said.

Scope identifies what will be audited: the type of service, which providers, and which or all payers, Kipreos said. Importantly, determining the scope also highlights what will not be included in the audit.

Consider the categories of patient population, timeframe, and type of service, Kipreos said.

Deciding on patient population helps you decide which payers you want to evaluate. It’s one way of streamlining your scope and, thus, your audit. If you’ve received letters from a particular payer, maybe you want to get the jump on any potential issue and start looking before it snowballs, she said. “It depends on the reason for the audit.”

One example she provided was performing an audit for medical necessity, and how the audit was focused on one provider, but because there was a question about a particular type of service, the audit had to look at all payers. She organized the audit around one service, based on a diagnosis — and, in fact, a diagnosis code that was being used inappropriately.

Don’t Feel Overwhelmed by Timeframe

Other things you establish when you set the scope: the timeframe for the selection of claims, the resources you or the auditor will use, and the policies followed.

The timeframe alone may seem overwhelming. If you have a specific concern, then maybe approach it like “let’s pull data that is relevant, relatively close to our proximity of time, so it’s easy for the provider to remember,” she said. If you haven’t done an audit in a while and it’s just time to do it again, pull everything since the last audit. If you don’t know how to choose a timeframe, just pick a week or a day and look at everything within that timing.

“You know, it’s a start somewhere,” she said. “Pick a day, pick two days, pick a week, whatever it may be, if it’s going to reflect the services you’re looking for.”

Focus on Type of Service, too

The type of service will obviously depend on the individual organization or provider. If your provider performs office and hospital services, you may want to look at those separately. “Do you want to divide those up into two separate audits, all hospital services versus office services, new versus established patients?” she asked.

If you have providers doing consultations, that’s an easy place to start to check in on documentation, and nursing home visits are easy and important to focus on, as well. You can look at different modifiers or procedures.

“Always start with all these questions, but part of determining the scope is thinking about the total process and how is this information going to be conveyed?” she emphasized.

“You have to know who you’re working with, too. You know, part of it is understanding personalities and who you’re working with and how best to convey information to that person. So if you’re an external auditor, part of it is knowing who you’re playing to. Know your crowd!”

And make sure there is transparency, especially if an external auditor is involved. An organization administrator may make assurances that everyone knows what’s going on, but it’s important that providers know that they’re being reviewed.

Don’t Miss Residents or Students

One more important question you need to answer when designing the audit: Know whether the providers are working with residents and if those residents are students.

“You never want that to be a surprise,” she warned. “That’s a gamechanger, when you find out residents or students are involved; so ask up front.”

It’s a simple question, but circumstances may make the real answer kind of murky.

“It’s an easy question to ask, and I’ve learned over time to ask it at least three different times and ask it of multiple people. Ask the administrator, ask the provider, ask anyone in that office, because you may find out that not everybody knows there are residents and students roaming around.

“Maybe they’re only in the hospital and the physician leaves the practice and goes to the hospital, and suddenly there’s a resident working with them. Find out, ask everything,” she emphasized.

Don’t forget that other clinical staff may affect the audit as well. For example, if there are nurse practitioners (NPs) working, then you may need to deal with incident-to. “Always ask that up front. Always,” she said.

Record these answers, too, as part of your audit. “I’m letting them know this discussion was had, it was made clear that there were no residents. That way, if it shows up later, I can say I was told there were not. Same with incident-to billing. How will I know if you are doing that? Or are you telling me it never happens? I want that statement, I want to understand what it is.”