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jenngar

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Hi all,

I am fairly new to auditing and was wondering if someone could give me some advice:

I am in the process of performing a prospective audit on a few of my providers and I have noticed that they are performing comprehensive exams on almost all of their patients regardless of reason for the visit.

For example: Patient was coming in for "follow up on headache, not as bad as it was when first seen 1 month prior, taking ibuprofen has been helping"... and a comp exam was performed. In my head I don't feel that the exam is medically necessary. However, I'm not sure how to bring up the issue with the provider.

In this scenario the exam didn't make a difference to the level of coding but it has effected the levels in some of the other notes that I have audited.

I would greatly appreciate any advice on how to bring up the issue with the provider or if I should even bother.

Thanks in advance
Jenn:)​
 
This can be a tricky situation. As auditors we need to look at all aspects of the documentation including medical necessity. However, the ultimate authority on medical necessity is the medical provider.

When we come across these types of issues we approach the provider with several examples of what consisted of minor or resolving issues where full exams were done, complete HPI, etc, and ask the provider questions. This is an opportunity to understand where the provider is coming from in doing a full exam and can be educational for us as the auditor. It also allows the auditor to explain to them how this would look to an outside or carrier audit and the red flags it raises. In addition we explain the possible financial impact this could have as well. Often times we find that the provider thought that they had to do a full exam each time or this was how they "have always done it".

Usually through an open and mutually respectful dialogue both sides can increase their knowledge and resolve the issue.
 
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Makes perfect sense they way you explained it. I will have to have a sit down with them and find out what their thought process is. Thank you Chelle-Lynn, I appreciate you taking the time to reply!
 
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