By Patricia Buttner, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CICA
There are many reasons physician practices might not routinely perform audits. These rationalizations range from lack of appropriate coding staff, perceived lack of time, “head in the sand” mentality, and choosing a reactive approach rather than a proactive one. But making the choice to not perform audits can cause headaches for practices down the line, explained Sandra Giangreco, RHIT, CCS, CCS-P, CHC, PCS, CPC, COC, CPC-I, COBGC, of CLA and Kim Garner Huey, MJ, CCS-P, CHC, CPC, PCS, CPCO, of KGG Coding and Reimbursement Consulting in their presentation “Developing and Implementing an Audit Program for Physician Services” at the 2019 Annual Clinical Coding Meeting on Saturday.
In today’s healthcare reimbursement landscape, there is a plethora of data collected and submitted to various payers for reimbursement of healthcare services. Providers in all settings should take a proactive approach to ensure reimbursement is appropriate and the data submitted accurately reflects the patient condition and the services utilized to care for and treat the patient, by utilizing both internal and external audits.
“The time invested in auditing on the front end may save significant back end recoupments,” Huey said. A comprehensive compliance plan is a vital component and should guide the practice in what to audit.
It’s important to perform both internal and external audits, according to Giangreco and Huey. Coding internal audits only is akin to “the fox watching the henhouse,” they explained. External audits offer the benefit of experience as well as an outside perspective that can bring new ideas to old issues.
It is imperative to select the correct external auditor, skilled in the practice specialty and familiar with the practice’s payers.
Audit scope depends on the size of the practice, but at a minimum should include coding and documentation. The accuracy of diagnosis coding in the provider office setting has come under the microscope. Compare what was documented and what was billed. Additional items to review include superbills, encounter forms, claim forms, explanations of benefits (EOBs), remittance advices, and payer policies and contracts. The practice may also want to consider identifying the top 10 reasons for denials, the top 10 billed services, and any other special issues that come to light.
Several methods can be useful when considering the sample size. It all depends on the type of audit being conducted. Approaches include: 10 encounters per provider, a random sample, one entire day, or the first ten listed on an EOB.
Recent claims can be audited to identify and correct potential current issues and provide education. Older claims audits will assist if there is a problem suspected.
Provider education should be timely and targeted, the presenters noted. Education can be provided to groups or to individuals to help ensure the documentation supports the billing and tells the entire patient story.Leave a comment