Responding to a Payer Audit
by Ellen Risotti-Hinkle, BS, CPC, CPC-I, CPMA, CEMC, CIMC, CFPC
Whether you work in a hospital or a physician’s office, chances are you will receive a payer audit request, at some point. Medical claims are under ever-increasing scrutiny as payers, both government and commercial, seek to uncover billing errors and reap monetary take backs. When that audit request comes to your door, how will you respond?
Success Hinges on Complete, Proper Documentation
We all know the saying, “If it wasn’t documented, it wasn’t done.” Payers know this saying, too. A payer audit typically begins with a request for medical records for a given service or services. The payer wants to evaluate the records to determine if the service(s) billed is supported by documentation.
A request may be for a random sample of patient records, or it may target a specific procedure, diagnosis, and/or billing pattern. The request may be for the complete medical record, or for specific dates of service. Whatever the case, what you include in your response, is key.
When submitting records in response to a payer audit, be sure to include a complete record pertaining to the service(s) being audited. Not only should you include the note for the given date of service, but also any lab test results, X-ray reports or other diagnostic services relevant to that service, any orders for these services, referrals, consultation reports, etc.
Also consider other areas of the chart the physician may have reviewed during the visit, especially if you are working with an electronic medical record. This is especially important if an E/M service is being audited. Office visit notes alone are often insufficient to reflect the complexity of a patient’s medical history and the physician’s medical decision-making. Because these are key components to determine the appropriate E/M level, lack of sufficient documentation may result in the auditor downcoding or disallowing the level of service billed.
Including additional documentation, such as problem lists, past history, family history, social histories, medication lists etc., to show that the physician reviewed this information at the visit, can help to substantiate the level of service billed. These key pieces of information often are not included with records submitted. Don’t fall into this trap: include everything relevant to the visit.
If you notice any relevant information is missing, include an addendum. Do not—under any circumstance—alter the records. If provider signatures are missing, an attestation statement should be included with the documentation, as well.
All documentation should be copied and submitted to the payer. Do not send originals!
Lastly, ensure that the audit request is completed and documentation is returned to the payer in the time frame requested. You do not want money taken back for a service that was appropriate because you failed to respond to the payer in a timely fashion.
Ellen Risotti-Hinkle, BS, CPC, CPC-I, CPMA, CEMC, CIMC, CFPC is a Coding Auditor with Visionary Health Group, Community Health Network in Indianapolis, Ind.
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