Wiki Does an auditor ask provider questions?

[LAT93]

Hello! I am hoping to get an answer or any references to be able to answer a question from my provider.

Let's say an auditor comes through and is auditing his charts, IF they have any questions will they go ask the provider? I was told no, that they would come in and do their audit, compile a list and then present the provider with the errors and fees. Is this right?

Thank you in advance!

 

[csperoni]

From my experience, auditors will perform their audit based solely on what is already documented. If the documentation is not clear or missing, the provider cannot amend after billing in order to receive payment.
I suppose it's possible there are reasons an auditor may have a question for a provider, but it has not been my experience.

 

[amyjph]

Are you talking about an external auditor or internal? This can be two very different things. Do you mean auditing of medial records/coding or are you talking about other types of audits such as facility and/or on-site encompassing the practice itself?

In general, external auditors are not going to ask providers questions during the audit process. The findings will be presented after the review. The medical records are speaking for the provider.
Internal auditors may ask questions but usually would not. It would be the same process but then there may be an educational component after with the provider for presentation of findings. It depends on the reason and scope of the audit. Is it part of a formal, internal compliance audit work plan for the practice? Is it an informal audit to help educate? Etc.

It can also depend on the type of external audit such as RAC, UPIC, ADR, CERT, TPE, etc. If your practice received a request it would explain the process depending on the audit and who is conducting it.

 

[LAT93]

From my experience, auditors will perform their audit based solely on what is already documented. If the documentation is not clear or missing, the provider cannot amend after billing in order to receive payment.
I suppose it's possible there are reasons an auditor may have a question for a provider, but it has not been my experience.

Thank you for your response. I think he was asking if they would come to him for clarification so there would not be a fee or strike against him? There has been a lot of education on documentation going on. This helps. Thank you!

 

[LAT93]

Are you talking about an external auditor or internal? This can be two very different things. Do you mean auditing of medial records/coding or are you talking about other types of audits such as facility and/or on-site encompassing the practice itself?

In general, external auditors are not going to ask providers questions during the audit process. The findings will be presented after the review. The medical records are speaking for the provider.
Internal auditors may ask questions but usually would not. It would be the same process but then there may be an educational component after with the provider for presentation of findings. It depends on the reason and scope of the audit. Is it part of a formal, internal compliance audit work plan for the practice? Is it an informal audit to help educate? Etc.

It can also depend on the type of external audit such as RAC, UPIC, ADR, CERT, TPE, etc. If your practice received a request it would explain the process depending on the audit and who is conducting it.

Honestly I was asking in general so all of this information is really appreciated. This is a learning curve for me as well so I am grateful for all of this. There has been a lot of education on documentation and that was one of the questions one of my providers asked me. If you have any suggestions on provider education (resources/links) education for myself on how do present documentation issues I would greatly appreciate it. I am currently working on my CDEO course and that has been helpful as well.

 

[amyjph]

Depending on the practice type, the specialty societies have good resources.
Examples: AAFP American Academy of Orthopaedic Surgeons - AAOS American Gynecological & Obstetrical Society - American Gynecological & Obstetrical Society - AGOS

This company has good resources: Medical Auditing Training, Medical Coding Audit Services
Of course AAPC: CPMA Certification and Exam - Medical Auditor
AAPC webinars, search the key word audit or auditing or CPMA. Example: Schedule, Prepare and Communicate Your Way to Successful Audits - Presented By Leonta Williams, CPC, CPCO, CRC, CEMC, CHONC - AAPC Webinar

CMS has lots of information: Medical Review and Education | CMS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

And, AHIMA: AHIMA Home

 

[Robyn07]

Not typically. External Auditors will come in, audit, do an Exit Interview and present findings/fees, etc. The Provider will then have a specific amount of time to review and rebuttal which could include amending notes. An auditor may or may not remove errors and/or fines & fees as they see fit. I would definitely suggest, hiring an internal auditor and/or an external auditor. Have random, periodic audits done to sharpen documentation and prepare at the same time for any external auditor.

 

[LAT93]

Depending on the practice type, the specialty societies have good resources.
Examples: AAFP American Academy of Orthopaedic Surgeons - AAOS American Gynecological & Obstetrical Society - American Gynecological & Obstetrical Society - AGOS

This company has good resources: Medical Auditing Training, Medical Coding Audit Services
Of course AAPC: CPMA Certification and Exam - Medical Auditor
AAPC webinars, search the key word audit or auditing or CPMA. Example: Schedule, Prepare and Communicate Your Way to Successful Audits - Presented By Leonta Williams, CPC, CPCO, CRC, CEMC, CHONC - AAPC Webinar

CMS has lots of information: Medical Review and Education | CMS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

And, AHIMA: AHIMA Home

Thank you so much. I will be looking into this!

 

[momo2]

Depending on the practice type, the specialty societies have good resources.
Examples: AAFP American Academy of Orthopaedic Surgeons - AAOS American Gynecological & Obstetrical Society - American Gynecological & Obstetrical Society - AGOS

This company has good resources: Medical Auditing Training, Medical Coding Audit Services
Of course AAPC: CPMA Certification and Exam - Medical Auditor
AAPC webinars, search the key word audit or auditing or CPMA. Example: Schedule, Prepare and Communicate Your Way to Successful Audits - Presented By Leonta Williams, CPC, CPCO, CRC, CEMC, CHONC - AAPC Webinar

CMS has lots of information: Medical Review and Education | CMS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

And, AHIMA: AHIMA Home

Do you know of any auditing tools for 30-day re-admissions? I just began a new job in a compliance department and this will be one of the audit's I am in charge of. Thanks for any information!

 

[momo2]

Depending on the practice type, the specialty societies have good resources.
Examples: AAFP American Academy of Orthopaedic Surgeons - AAOS American Gynecological & Obstetrical Society - American Gynecological & Obstetrical Society - AGOS

This company has good resources: Medical Auditing Training, Medical Coding Audit Services
Of course AAPC: CPMA Certification and Exam - Medical Auditor
AAPC webinars, search the key word audit or auditing or CPMA. Example: Schedule, Prepare and Communicate Your Way to Successful Audits - Presented By Leonta Williams, CPC, CPCO, CRC, CEMC, CHONC - AAPC Webinar

CMS has lots of information: Medical Review and Education | CMS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

And, AHIMA: AHIMA Home

Depending on the practice type, the specialty societies have good resources.
Examples: AAFP American Academy of Orthopaedic Surgeons - AAOS American Gynecological & Obstetrical Society - American Gynecological & Obstetrical Society - AGOS

This company has good resources: Medical Auditing Training, Medical Coding Audit Services
Of course AAPC: CPMA Certification and Exam - Medical Auditor
AAPC webinars, search the key word audit or auditing or CPMA. Example: Schedule, Prepare and Communicate Your Way to Successful Audits - Presented By Leonta Williams, CPC, CPCO, CRC, CEMC, CHONC - AAPC Webinar

CMS has lots of information: Medical Review and Education | CMS).

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/CERTMedRecDoc-FactSheet-ICN909160.pdf

And, AHIMA: AHIMA Home

Do you know of any auditing tools for 30-day re-admissions? I just began a new job in a compliance department and this will be one of the audit's I am in charge of. Thanks for any information!

 

[ggoode66]

Hello! I am hoping to get an answer or any references to be able to answer a question from my provider.

Let's say an auditor comes through and is auditing his charts, IF they have any questions will they go ask the provider? I was told no, that they would come in and do their audit, compile a list and then present the provider with the errors and fees. Is this right?

Thank you in advance!

Like someone else posted it depends on the type of audit. if it's a payor audit then they most likely won't ask for anything. If it's an internal audit, they might, it really depends on the auditor. When I'm doing internal audits, I will ask the provider or the point of contact if I see a pattern of something not in the chart to make sure I'm not missing it or something else. It could be they are down people, so items are not being scanned in that I need, or that the provider has a habit of documenting something in an odd place. It happens. I usually compile a list as I'm going so I"m not asking often. Personally I would rather ask if something is documented elsewhere, then deliver results on the audit to find out, that the information was in a different area, or the had been some sort of glitch in the EMR