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The Importance of Self Audits

The Importance of Self Audits

Self audits are an important step that medical organizations of all types can take to protect themselves from potential lost revenue (or worse) by identifying coding, billing, and documentation problems before a payer does. All practices should make self-audit a part of their coding compliance program.

What Self Audits Can Achieve

Self audits allow you to identify:

  • Fraud and improper payments
  • Improve patient care
  • Lower the risk of an external audit
  • Identify educational opportunities with your organization
  • Create a vigorous culture of compliance

Spotting problem areas allows you to initiate corrective action and prevent more damaging financial repercussions, later. They also allow you to identify possible missed revenue opportunities.
The Office of Inspector General (OIG) recommends that a facility or provider start with a baseline audit, which should cover at least three months and should include a random selection of five to 10 Medicare/Medicaid records per professional who bills the Centers for Medicare & Medicaid Services (CMS).

Auditing as Opportunity

Self audits may seem like a daunting task; however, creating a positive atmosphere around self audits is the real challenge. Self-auditing provides distinct organizational value that exceeds compliance, and should be viewed as a natural and positive process.
Begin by describing your goals for self-auditing. Each organization is different, and I recommend starting with simple goals and achieving those, first, before moving to the harder ones. For example, start with the goal of identifying improper payments and self-audit through that lens. Next move up the ladder to validating provider documentation and coder accuracy.
As you move along your self-auditing roadmap, you will naturally discover process improvements. Improved patient care, along with improved compliance, should be the goal. Working through self-audits in this phased approach helps to remove any barriers to change, and help to achieve high mark from your patients and employees, alike.

Meeting OIG Compliance

A key goals while working through your roadmap is to adhere to OIG compliance rules. If the OIG ever knocks at your door, not only will you have a roadmap that shows your commitment to compliance, you’ll also have real self-auditing artifacts to back it up.
Here are the steps to develop and comply with the OIG self-audit requirement.

Certified Professional Medical Auditor

  1. Determine who is accountable for specific roles within the organization
  2. Assign a strong coder who can review the medical records and bills for accuracy of the information from coding
  3. Accounts Receivable/Payable work to confirm the charges are accuracy for services billed
  4. Medical Records verify the medical records are complete and all diagnosis codes are documented and are currently being treated
  5. Set a time frame: The OIG recommends quarterly audits
  6. Determine the number of charts to by reviewed
  7. Specify the types of accounts to review. For example, for outpatient accounts you should: Review ICD-10 codes; Review charges (important for potential overcharging or missed revenue), and; Review providers level of care and does their documentation support the level selected
  8. Reports should include all your findings: the good, the bad, and the ugly. Included educational resource so the coder and provider can improve the accuracy
  9. Meet with the coders and provider to go over the results and office education pointers.
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Robin Ingalls-Fitzgerald, CCS, CPC, FCS, CEDC, CEMC is company founder CEO/President of MRS. She has been a coder for 23 years and holds certifications with the AHIMA and the AAPC, and knowledge of Medicare coding and billing guidelines, NCD’s, LCD’s and CCI edits is a resource to facility and practice billing departments.

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