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
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.”
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?
- 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.
- Create an Internal Compliance Plan
Conduct an Internal Audit. It should include your Clinical Documentation and your Billing/Coding Department.
- 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.