Question Auditing for medically impossible days

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Coeur d'Alene, Idaho
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Good afternoon! I need to do a time-based audit on a provider who is showing risk for medically impossible days. Does anyone have any resources they recommend? I don't have the first clue where to even start with this audit. Any and all help would be appreciated!
 

thomas7331

True Blue
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There really aren't any specific resources for this. When a billing pattern identifies risk, what that indicates is that there is a relatively high likelihood that the codes submitted are false, and the first step is to request documentation and verify whether or not that is the case, and that is just regular code auditing work like any other - you just have to look and see if the documentation supports the claims. One thing to consider with time-based impossible edits is that if there are legitimate 'incident to' services being billed under that provider's credentials, it could create a false positive when time is considered. Or there could be other factors that you'll uncover when you review the records that show that the provider is submitting valid bills.

If, however, the documentation supports the codes and yet you are still looking at an 'impossible' scenario (e.g. an individual provider has documented more than 24 hours of face-to-face time with individual patients on a given date), that raises suspicion of a different kind, namely that the documentation has actually been falsified. This is a much different type of thing to prove, and may require an investigator with more of a legal and/or forensic background. It may be necessary to do things such as review scheduling records, interview patients to inquire whether or not the services that are documented were actually rendered, and collect other evidence to actually build a case in order to be able to prove something like this in a court of law. Or, if you are auditing on behalf of a payer and the suspicion is high enough, the payer may have internal options available as well, such as to simply terminate the provider from the network, that don't involve legal action.

Don't know if this helps any, but maybe a start?
 

twtcpc

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I agree with Thomas and having had something similar myself, I would ask if you have an EMR that you can verify the patient appointment times/provider's calendar or template use? Utilization/comparison of those might help build a stronger case that you could take to your senior management.
 
Messages
192
Location
Coeur d'Alene, Idaho
Best answers
0
I agree with Thomas and having had something similar myself, I would ask if you have an EMR that you can verify the patient appointment times/provider's calendar or template use? Utilization/comparison of those might help build a stronger case that you could take to your senior management.
We do have an EMR that I can use to help verify. Thank you!
 
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