What's the Effect? Medical Auditors Ask Questions.

A few weeks ago, while on a road trip, I was catching up on some podcasts. One caught my attention because of its simplicity and the ability to apply the logic to so many real life events. In this particular program there was an interview with a professor at Cornell University who, in 1999, along with one of his students, published a paper describing an event now well known as the Dunning-Kruger Effect.
The basic premise of this effect is quite simply, “we don’t know what we don’t know.” The Dunning-Kruger Effect is based on the results of testing individuals who consistently believed they scored in a higher percentile than their actual scores reflected. An article written by the Professor (Dunning) and the student (Kruger) referred to this as “unskilled and unaware;” some may phrase this as an “illusionary superiority.” The flip side of this argument was also proven by those test subjects who scored in the higher percentile. These students believed their peers would also score well, so they believed that their individual scores would be lower than that achieved.
As I was listening, I thought about something I always say when talking about medical auditing, whether it be with providers or coders. Always remember to ask “why and how.” Why is there a variance and how did the auditor come up with that variance? Perhaps the auditor only believes he or she knows a rule when, in fact, his or her understanding is not correct. Sometimes, someone can have such a deep belief in their “rightness” that it convinces everyone else, as well. Some individuals just convey more confidence than others, but this does not necessarily mean that person is always correct.  We need to trust in the theory that, perhaps, someone just does not know what they do not know. Some individuals may not be aware that their comments are really just opinions, and not facts.
This same concept could apply to the providers. I am sure we have all been in that situation when you are meeting with a provider who states quite confidently that they heard at a meeting, in the lunchroom, with a group of other providers, that it is not necessary for the provider to document the history of present illness (HPI) portion of the history (or any other interesting non-truths). The provider is quite confident because the person who told it to them was confident. So confident is the provider, that suddenly we begin to second guess ourselves and begin to wonder, when did the rules change? This is one scenario I would call “unskilled and unaware.”
If you decide to take on the responsibility of performing an audit, take the time to know what you should know. Be skilled and know what affect you will have, based on your findings and results.

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Jaci Kipreos

Jaci Kipreos, CPC, COC, CDEO, CPMA, CRC, CPC-I, CEMC, has been in the field of medical coding and auditing for over 30 years and received a Bachelor of Science degree in finance from Virginia Tech. She has worked in a variety of practice settings and has expertise in coding for family practice, urgent care, obstetrics and gynecology, general surgery, and Medicare’s teaching physician guidelines, with an emphasis on compliance with evaluation and management guidelines. Kipreos has been an instructor for various AAPC workshops for the past 10 years and is a frequent speaker at AAPC’s national and regional HEALTHCON conferences. She has also provided presentations for the American Association of Nurse Practitioners state event in Virginia and the national event for the American Association of Medical Assistants. Kipreos is a past president of the Richmond, Virginia and Charlottesville, Virginia local chapters, and served as president of AAPC’s National Advisory Board from 2015 to 2018.

Latest posts by Jaci Kipreos (see all)

• Is Becoming an Auditor In Your Future? - October 3, 2022
• Changes in Healthcare Come Each Year and It's a Good Thing - June 30, 2016
• What's the Effect? Medical Auditors Ask Questions. - May 17, 2016