Massachusetts Medical Society: Adding Value to Practice: Being Ready for a Billing Audit

Adding Value to Practice: Being Ready for a Billing Audit

Vital Signs: September 2012

We are no longer operating in a world of “if we get audited,” but rather “when we get audited.” Your practice can successfully survive an audit with preparation, education, and a well-outlined internal plan.

Recently, the North Carolina Medical Society released a YouTube video highlighting inefficiencies in the audit process and the dangers of not being prepared or not understanding a practice’s role in billing audits.

While viewing the video, I found myself cringing because the featured practice was assessed a $1 million fine by CMS. The practice then spent over four years and $300,000 fighting the audit findings.

I often consult with MMS members about proper compliance techniques. In speaking with practices, I routinely encourage them to prepare in advance for audits rather than simply waiting for the day when a letter arrives from a health plan requesting medical records. Education, understanding, and proper planning can save your practice significant time and money.

  • Educate yourself.Know what each health plan requires as part of its integrity program or claims review process. Information can be found on health plan websites or by reading your contracts.
    Understand what the time period is for records review, whether or not an auditor is allowed to visit the practice site, and the frequency with which auditing can occur for each plan.
  • Know where you are at risk.Improper documentation or processes that do not support billing levels are often the source of error or risk. Consider engaging an external auditor on an annual basis to perform a mock audit and discuss the findings with your practice. Don’t forget to involve key staff in the mock audit. Consider it a test run for the day you receive a letter from a health plan requesting records. Use this as an opportunity to outline the internal process your practice will take.
  • Identify a designated staff member to manage the process. It is important to have a designated full-time person responsible for managing an audit. Do not have a temporary staff member make photocopies of charts and drop them in the mail. That person may not be familiar with what the audit is looking for and may not be familiar with how the physicians in the practice document their charts.
    Choose someone familiar with the practice, how the physicians work, and where things are located within the chart. This person will be able to see if something important is missing or highlight the location of key information for the audit reviewer.
  • Organize the information and flag important pieces for the auditors.Practices that take this step often have high levels of success. If things are hard to find, the auditor may miss them. In most cases, the auditor is not on site and you will not have an opportunity to point out where pertinent information is located.
  • Make copies of submission materials.Make copies of everything you submit, so if something accidentally goes missing, it’s easy to provide to the auditor. Also, if your practice questions or disputes an audit finding, knowing exactly what records were sent will help speed response time.

— Kerry Ann Hayon

For more information on the auditing process, visit:

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