Auditing Strategies That Work
By Rhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, COBGC, CPEDC, CENTC
Oftentimes we struggle to figure out what should be done in our practices with regard to what types of audits, or what services we should audit, to ensure we are in compliance. Following the tips below can help us put into perspective what direction we should be taking.
How Many Audits?
The number of audits can depend on several parameters. First, what does your compliance plan require? Look to your compliance plan first to determine how many audits per provider yearly. Most compliance plans spell out how many audits should be done and how frequently.
If you perform these audits and problems arise, you’ll want to do a more focused audit to determine the extent of any errors. More frequent audits may be required based on findings.
What Types of Audits?
Take a look at the scope of OIG work plans, health plan communications, or RAC work to then determine a focus beyond your compliance plan. Are you providing any services that the government or other payers are communicating about? If so, it’s a good idea to monitor services. You can also run a utilization report and see what types of services you may want to audit based on utilization. High dollar items are always under scrutiny and should be monitored for compliant billing as well as high-level E/M services.
You may also want to look past compliance audits to reimbursement audits. Oftentimes practices are not reimbursed properly based on contracted rates by health plans. A healthy practice will routinely pull Explanation of Benefits (EOBs) and spot check to make sure services being billed are being paid and reimbursed at contracted rates. If you find denials for the same services or procedures, an audit is a great way to determine if policies and procedures need to be changed or if a meeting with a health plan is required to get the issue resolved. This is an important type of audit to perform to stop any revenue leaks in your practice.
Having trouble determining exactly what your payer is looking for? Utilize this resource to take you straight to the health plan’s policies and procedures http://www.aapc.com/resources/links/health-plan-list.aspx
Whatever audits you perform in your practice, they should all share a common thread, and that is education. It is not enough to simply perform the audit and document the results. All staff and providers should be educated on the findings, and areas of weakness should be discussed. Any deficiencies should be addressed with further education so that the problem does not continue.