How to Prepare for a Health Insurer's Audit - DoctorsManagement How to Prepare for a Health Insurer's Audit - DoctorsManagement

How to Prepare for a Health Insurer’s Audit

By Shannon DeConda, CPC, CPC-I, CPMA, CEMC, CMSCS | July 17, 2014

Shannon DeConda, a partner with DoctorsManagement, headquartered in Knoxville, Tenn., had a pediatric practice call her for help after finding out United Healthcare was auditing the practice. A physician assistant at the practice had helped a doctor take a patient’s history and initialed the paperwork to speed things up. When United Healthcare found the physician assistant’s initials rather than the physician’s, the company audited the practice to recoup money it had paid for those services.
DeConda said her firm is seeing as many, if not more, audits performed by commercial carriers as by the federal government. As insurers focus on reducing costs, they have learned that taking money on the back end is as good as saving it upfront. Because audits are an increasing part of the new insurance frontier, physicians would be wise to be proactive and prepare for the possibility.
Understanding risk 
The most important thing providers need to understand in regard to audits is their own risk, DeConda said. Every office should have an internal compliance plan and should be doing proactive audits either through an outside firm or internally.
A baseline annual audit should include 10 to 20 records per provider, DeConda said. She recommends pulling a random sample to get the best understanding of where a practice is at risk for audits. Any aspect of patient care in which a practice is an outlier relative to what is expected is a risk area. Say, for instance, the national average of the proportion of patients in a nephrology practice that receive infusions is 20%, but a practice’s audit reveals that its proportion is closer to 40%. Knowing this allows the practice to begin looking through records to determine why the rate is so high relative to the national average. An audit can reveal areas of waste or abuse and if treatments were medically necessary and supported by documentation.
Read the full article at Renan & Urology News…