Practice Management Alert

Preparation Can Get You Through this Stress-Inducing Process

You’ve received a “You’re being audited” letter. Rather than panicking, you can take control and engineer a positive outcome for your practice.

In the March 2017 Practice Management Alert, we covered seven concrete steps to take if you’re being audited. In this month’s installment, we’ll focus on the auditing experience itself: How to respond, what you should and shouldn’t worry about, how you can make it easier for yourself and your staff.

What Do They Want From You?

An audit letter may be an unwelcome sight, but it should never be a cause for uncertainty. The letter should spell out exactly 1) which records the payer needs, and 2) the deadline by which you should have those records ready to be audited.

It’s your responsibility to read all audit letters thoroughly and to respond as soon as possible. This is especially vital when the auditor is looking for a reimbursement of over-coded or over-billed money. “If you don’t respond by the deadline, you’re going to be considered to agree with their charge, and you’ll owe the money back,” Stark Coding & Consulting Vice President Barbara Cobuzzi tells Practice Management Alert.

Respond with evidence: The letter can also offer you a golden opportunity to avoid the audit entirely. You can appeal the claim, provide all the supporting documents to make your case, and make an in-person visit from the auditors unnecessary. The better you build your case through explanations and evidence, the less time you’ll spend across the table from scary auditors. This processcan be a very effective way of dealing with audits by Recovery Audit Contractors (RACs). “They base their audits entirely on computer modeling,” Cobuzzi explains. “So don’t just automatically accept what they say!”

One stress-relieving option that practices often fail to take advantage of is simply asking for a different date than the one first proposed by the auditor. Particularly when the auditor shows up unannounced or gives you only a day or two notice, it is fully within your rights to ask for them to come back on a more convenient day (for example, at a time when you’re not seeing patients).

Cause for alarm: Unannounced audits can be the scariest, but the only ones you should worry about are the kinds connected to allegations of fraud and abuse: visits from Zone Program Integrity Contractors (ZPICs), OIG or even armed FBI agents. “That isn’t even an audit — they usually have a warrant at that point,” says Cobuzzi. “There should be no reason for an audit to be unscheduled.” Such visits are very rare, and well-behaved practices (like yours, of course) have nothing to fear. Instead, ask unexpected auditors to come back another time.

Assemble the Right Team

Your first call when you get an audit letter should always be to your healthcare attorney. The lawyer will help to “guide you through the audit process, to communicate with the auditors, and to be prepared if it is necessary to challenge the audit findings,” writes Florida-based attorney George Indest III for his Health Law Firm blog. They will be present throughout the process, and keep the auditors within their legal boundaries.

Another vital member of your audit team is the person who best knows the practice’s operations and records, most likely the practice manager. He or she can pull exactly the records requested, as well as all supporting documents, and is more likely to be calm and confident in the face of scrutiny and to be able to answer any questions that come up.

Borrowing a metaphor from football and basketball, Cobuzzi recommends protecting your practice by running “man-to-man defense, not zone defense.” That means having “one person from the practice for every person from the payer. You do not want them diving into charts where they don’t belong,” she says. An audit should be a narrowly targeted inquiry, not a random fishing expedition, so never let an unaccompanied auditor rifle through your files looking for problems.

Be Ready to Supply Complete Documentation

Most reimbursement audits are triggered by specific red flags, such as “billing for services and products at a rate higher than surrounding area doctors, or at a rate higher than you traditionally have charged,” Indest notes. RACs are bounty hunters, getting a cut of any overpayment they identify, so they scan for details like these to make their living. Because they’re only asking for documents related to those flagged cases, it’s in your interest to provide a full accounting of those cases. The sooner you show them the files they requested, the sooner they’ll resolve the audit.

You should make these files as clear and complete as possible. “Don’t just pull the date they ask for” Cobuzzi advises. “Pull earlier patient visits related to that date, because there’s material in the earlier visit that refers to the later one. If your notes on the record refer to a patient’s filled-out medical history form, pull a copy of that form to give to the payer. You have to make sure that everything is in front of the payer to be able to fully audit that note.” Anticipate what they’ll need, and you’ll have an answer for any question they might ask.

Fact books for all: For additional protection, it’s essential that both you and the auditor have identical copies of all the records. In fact, says Indest, “when we provide records to a Medicare auditor, we make a complete copy for the auditor, for the client, for us (legal counsel) and two for your future expert witnesses (to challenge any audit results) to use.” These records should read like a book, complete with identical page numbers for quick reference. That way, everyone comes into the audit literally on the same page.

Pre-review advantage: By self-auditing in advance of their arrival, you’ll know what the auditors will find before they even ask. It’s like seeing the future! Since you’ve already copied all the relevant records they’ll use to investigate overpayments, you have all the information you need in front of you. When the fateful audit day finally arrives, you’ll be more prepared and less worried, resulting in a better experience for all.

The Audit’s Over: Now What?

Once you’ve made it past the in-person audit, you’ll receive the results by mail. Chances are you either successfully made your case to the payer and owe nothing, or you owe the payer a reimbursement.

This doesn’t have to be the end of the road, however; you may appeal a decision you disagree with. Keep in mind that “you will only have a short period of time to file an appeal should you so desire, usually 30 days or less,” says Indest. You’ll go before the payer’s review board to make your case again. And even if this avenue fails, you can demand arbitration or go through the legal system to resolve the matter.

Silver lining: Ultimately, the audit can even have positive effects on your practice. Being audited is no fun, of course, but it can offer a chance to review what you’re doing well and not-so-well now and to fix it going forward. If you end up catching coding or billing errors that result in a repayment, you can set up systems to prevent such errors in the future. Prepare thoroughly and stay calm during the process, and you could end up with a better practice than before.