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Minimizing The Risk Of An Audit
By Rachel M. Mitchell, CPC-H

Avoiding an audit is not difficult when you consider the number of audits there are in relation to the number of physicians and practitioners submitting claims. According to various medical publications the number of audits will increase in the near future. However, the good news is that there are methods to keep the risk to a minimum.

There are several things that can prompt an audit; A practitioner could be selected at random or a disgruntled patient may allege that a practitioner is being fraudulent. Positive measures must be taken to ensure minimal risk. Some ways to reduce risk of an audit are as follows:

· Practitioners must communicate effectively with patients regarding all care. Do not give patients a reason to call a fraud and abuse hotline because of a misinterpretation.

· Documentation should be legible and detailed.

· Perform random coding and billing audits.

· Provide continuing education for your staff to ensure competency and accuracy.

· Implement a compliance program comprised of a detailed outline and instructions on all company functions.

· Keep all coding reference books up-to-date. CPT adds and deletes codes on a yearly basis. If you attempt to bill a deleted code it will be quickly noticed by an insurance carrier.

· CPT codes must reflect the services performed, not the desired reimbursement.

· Diagnosis codes must reflect documentation. Never use a diagnosis that is not thoroughly documented.

· Never bill for a procedure or service that was not documented

· Read newletters and publications to stay informed of any coding and billing changes. Print the Federal Registry once a year for governmental updates.

· Assign a member of your staff to audit Medicare and Medicaid rejections. Investigate any trends and take corrective action to ensure proper billing.

One method that Medicare uses to determine audit targest is called profiling.. They use a database of frequency distributions of CPT codes. The computer system can perform an audit of a specific physician’s code usage and compare the results to the national average. Comparison is determined by specialty. Any physician who demonstrates a pattern noticeably different from the average is called an “outlier”. Outliers have the increased risk of being audited. Run monthly utilization reports from your billing system and compare them with the previous months, checking for any significant changes. If a change is found pull charts and compare documentation to the CPT codes billed.

By taking the above steps, practitioners can actually see an increase in revenue because there is decreased pressure to downcode charges because of insecurity about what is correct.

For more information regarding this article or other previous articles, contact Ms. Mitchell at rmitchell@ams-nc.com or 919-477-5152.