The ABCs of Auditing

Transcription

1 The ABCs of Auditing Presented by: Jonnie Massey, CPC, CPC-P, CPC-I, CPMA, AHFI 1 Agenda When and how to identify records to audit Identifying red flags Resolving your audit 2 1

2 When Should You Start Auditing Now! Conducted by a qualified auditor Audits should be a routine practice A baseline audit should be first 3 Getting Ready to Audit The medical record Code books watch the year Specialty society publications CMS guidance Audit tools paper or electronic Other software - Word, Excel Resources (see end of presentation) Other auditors as needed 4 2

3 How Often Do You Audit? Minimum is once per year if audit results indicate compliance Increase the frequency of audit if errors are identified Internal auditors may conduct ongoing audits External Auditors less frequently Larger practices vs. smaller practice Know when to ask for help! 5 Where Do You Start? Individual providers new to practice? Peer comparisons Codes Claim denials Known industry audit triggers Post implementation of the EMR New coder, biller, billing company Pre-payment vs. Post payment audit 6 3

4 How Many Charts? Run utilization report Audit by top codes billed? Dollars? Consider audit by date of service Start small 10 records? More recent dates of service don t get overwhelmed 7 Tips for Auditing Medical Necessity Review records to ensure medical necessity is documented Is the reason for the visit clearly documented? Watch for unacceptable documentation Here for follow-up No complaints Doing fine 8 4

5 Tips for Auditing Individual Practitioners Consider auditing pre-submission Ensure all elements of the medical record are compliant How does this practitioner compare to others in the practice? Communicate early, provide education and include the process in your compliance plan 9 Peer Comparisons Do the practitioners in your practice document and code similarly? Do you have an outlier..why? Does your practice have a sub-specialty Specialty equipment or services? Is your practice different from similar practices? 10 5

6 Types of Audits Pre-payment/pre-submission Retrospective Audit - Post Payment Focused Audit Random Sample 11 Codes and Claim Denials Review all claim denials Use caution when changing codes and rebilling Track denials by payer, group/member # and code Look for patterns, correct problems 12 6

7 Audit Tips If it is not documented, it can t be billed aka if its not documented, it didn t happen Missing documentation cannot be produced later to outside auditors ensure compliance now Is the medical necessity for labs/test documented or easily inferred? Is the chart complete and organized? 13 What to Look for Known Triggers Patterns of claim denials Patterns of re-billing with codes changed Duplicate Claims Missing documentation No date of service listed Patient name missing Unable to identify practitioner Unable to read records 14 7

8 What to Look For con t Record is not signed, initialed No chief complaint Consultation billed but is it? New or established patient All services warranted and documented? Up-coded Down-coded Patient not present but face to face visit? Cloned or canned records 15 What to Look for con t Non-covered service documented and billed Wrong code assigned by DME supplier E/M billed during global period Out of sequence billing Incorrect Modifier Usage Time based codes 16 8

9 DME Issues Always validate procedure and diagnosis codes Is this new to the industry? Is this FDA approved? Do you need an ABN or waiver? Who bills the health plan? How much will this cost? 17 Global Billing Validate that services provided in a global period are coded correctly see chief complaint Know what is included in the global package Are claims billed timely? Are visits billed first, then surgery/procedures? 18 9

10 Out of Sequence Billing Services are billed out of date order Could be a red flag to outside auditors Audit for timely completion of records and submission for payment 19 New Equipment Were services previously outsourced? Consider auditing before and after new equipment Do patterns change if this was previously outsourced? Has frequency increased? Is medical necessity in the record? 20 10

11 The EMR Audit for canned or cloned records Does documentation look the same for all patients? All visits? Do the vitals change visit to visit? Does the practitioner have free text ability? Has the level increased post implementation? Are the patients really sicker? 21 More on the EMR Watch for date of service vs. closing the record Was the EMR closed timely and submitted? Did the audit identify additional training needs? 22 11

12 Avoidable Errors Wrong insurance / termed insurance Solution: work with office staff to verify insurance coverage prior to seeing patient. Auditing claim denials will help identify this costly issue A corrective action plan will include the resolution to this issue 23 Time-based Codes Ensure documentation meets code requirements Compare codes, compare practitioners Watch for services where counseling was more than 50% of visit Time is a determining component Is description of counseling included? All other criteria met? 24 12

13 Resolution of Audit Findings Summarize audit findings in a narrative report to the physician / practice Use Excel to track the audits by Procedure and diagnosis code Date of Service Health Plan / Payer Name (include group number) Practitioner Billed amount Paid amount Denied amount / reason 25 Audit Resolution Education should be an important component of your audit findings report Track audit results Track education as a result of audit findings Reward compliant results Continue the process Seek help from outside when you need to Audits should be part of all compliance plans 26 13

14 Resources Health Insurance Portability and Accountability Act National Center for Quality Assurance Food and Drug Administration 27 Websites Office of Inspector General Comprehensive Error Rate Testing Centers for Medicare and Medicaid Services Recovery Audit Contractor Program AAPC

15 In Summary Auditing is important to ensure a healthy practice Always seek help when you need to Keep up-to-date on coding and documentation guidelines The best defense is still a good offense! Demonstrate you are taking steps 29 Thank You Questions? 30 15