Practice Management Alert

No. 1 rule:  Sheath that sharp tongue

When your medical office is responding to a private-payer audit of evaluation and management services, don't lose your cool.
 
In fact, the SMART reaction is the most intelligent, said Stephanie Jones, NR-CMA, NR-CAHA, CPC, vice president of operations at Aztec Medical Systems in Miami. During the recent Coding Institute teleconference -How to Respond to Private-Payer E/M Audits,- Jones gave a prescription for a pitch-perfect response when dealing with private payers. (For more tips on dealing with audits from private insurers, see -Your E/M Claims Could Make You a Billing Outlier- earlier in this issue.) Follow this script to the letter, and that audit will be over before you know it:

-S- Is for -Shhhhhh-
 
The first thing to remember when under the auditor's microscope is word choice. Remember whom you are talking to, and do not say anything that makes you appear belligerent or uncooperative. Put simply, -Don't say things you-ll regret,- Jones said.

-M- Is for -Manage-

To make your audit as painless as possible, you need to assign the proper staff to oversee the appeal, Jones said. This person should be familiar and comfortable with the rights of the provider in your particular state, and with  the current documentation guidelines and E/M CPT code changes that are issued each year.
 
So what if your office cannot spare a person with that kind of knowledge for an appeal? -Hire someone from a consulting firm,- Jones said.

-A- Is for -Ask-

Perhaps the most vital component of the SMART reaction is asking the auditor questions. Your inquisitive nature will help your appeals process immensely in the present and future.

How? The more you ask about the audit, the easier it will be to give the auditor the specific info he wants for the appeal. Also, asking an auditor specific questions can help you get a handle on possible future audits from other insurers.

For example: If you ask the auditor why you are being audited, and he responds, -Because you are an outlier,- it could be a sign of things to come.

-If you are an outlier with one payer, you could be an outlier with another payer,- Jones said. 

Also, suppose your office is being audited because of an increase in use of code 99214 in your geographic area. -If there is a 99214 increase in your region for one payer, chances are you may get audited by another payer for the same code,- Jones said.

Jones said that during the audit you should ask questions such as:

- Why was our office selected for audit?
- What is the deadline for the audit?
- What are our appeals rights?
- What are the auditor's credentials?
- Will you send us a copy of the audit results?
- What happens if the office does not respond to the audit?

-R- Is for -Review-

Before you submit the documents to the provider, -have a qualified reviewer audit the documents,- Jones said. If you do not have a qualified reviewer on staff, find a reputable consulting firm and hire it for the task.

-T- Is for -Trail-

You want to produce a detailed audit trail from your prior review. This is a powerful tool that helps to even the playing field with the provider. Make sure you submit the audit trail with the documentation for the audit, Jones said.