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How To Survive An Audit? It’s Easy If You Do It Smart!

March 6, 2016 by Vanessa Best

When a healthcare provider hears the word “audit” it causes the heart to race, a knot in the stomach, possible headache……. And then the following questions come to mind, “Did I document correctly?” “Will I be opened to embarrassment?” and the biggest question

WILL I HAVE TO PAY MONEY BACK?

The audit process in healthcare administration is very complex. It unearths clinical documentation either created electronically or in the very common “medical paper chart”. An Audit means a Clinician must hand over documentation or “patient notes” to an auditor which is usually from an  Insurance Company that has previously paid a claim or a Recovery Audit Contractor

audit concept on document folder

What do auditors look for?

  • Does the documentation support the paid claim?
  • Does the documentation contain the needed specificity and level of detail to support the new ICD-10 diagnosis codes which, as of October 1, 2015 has mushroomed into 68,000 diagnosis codes opposed to 13,000 diagnosis codes in ICD-9?

What is the biggest risk of a “failed audit”?

The Doctor’s Office or Practice has to Pay Back Money To The Insurance Company on Claims That were Previously Paid.
This is sometimes called a “Negative Payment Adjustment”

“Think of a negative entry on your bank account. A fee or adjustment. Negative Payment Adjustments don’t equal more money It equates to LOSS of revenue. A “take back” of funds.”

MAN AT DESK See the CMS website (Centers for Medicare & Medicaid Services) about payment adjustment information

What three steps should a practice do to prepare for and survive an audit?

  1. Review Policy for Midlevel Providers
    If your practice includes Midlevel Practitioners such as Physician Assistants and/or Nurse Practitioners, ensure you are familiar with your State and Plan guidelines for compensation, billing and documentation.
  2. Create an Internal Compliance Plan
    Conduct an Internal Audit. It should include your Clinical Documentation and your Billing/Coding Department.
  3. Provide Documentation Training
    ICD-10 has added new nuances to the specificity required in documentation. The diagnosis codes have increased from 13,000 ICD-9 diagnosis codes to 68,000 ICD-10 diagnosis codes. Training on Clinical Documentation Improvement is key to preparing for and surviving an audit.

CMS has provided a resource for the Claims Review Process.
Precision Healthcare Consultants provides pre-audits for practices. Contact us for free consultation.

Filed Under: Billing & Coding Tips

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  • Home
  • About Us
    • About PHCC
    • PHCC in the News
    • Awards
    • Testimonials
    • Case Studies
  • Services
    • Government Contracting Federal, State, City
    • PAS – Personal Assistant Services
    • HealthCare Administration
    • Health & Safety Services including COVID-19
    • Construction Support Services
    • Workforce Development Services
      • Precision Internship Program
    • PHCC Health Equity
    • Protocol/Clinical Trials Support
    • CME Courses
  • Training
    • OSHA Safety Training
    • On-Line Safety/HR Training Portal – Spanish Course Available
    • Traveling Medical Coding School
    • On Site / Remote Training
    • Workforce Development
      • Precision Internship Program
    • Small Business Development
    • Medical Coding Certificate Program – Online School
  • Contact
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