4 Steps to Achieving Audit Success

Notice of an audit can elicit fear and concern. Practice these approaches to better ensure more successful outcomes and less stress.

It’s no longer a question as to if you will be audited as a provider in the outpatient wound clinic setting, but when. If you’ve not yet been party to the audit, be prepared for your heart to drop to your toes and to fear the worst when the time comes. Fact is, all of us will face this challenge eventually. This article will provide the “nuts and bolts” of the auditing process as well as four tips to ensure that providers take a healthy mental approach to audit and gain a successful outcome. As an example, we’ll discuss a real-life audit case.

Tell The Whole Story

Think back to when your wound clinic first opened. For those of us who began our wound care careers when charting was done on paper, we filed the medical necessity documentation in the chart, sometimes in a special section. Any diagnostic results supporting our medical decision-making, along with any prerequisites outlined in our local coverage determinations (LCDs) were obtained and filed where we could easily retrieve the information. Now that we use electronic records, we must continue to assemble the documentation necessary to prove medical necessity. Most of us scan this documentation into our electronic health record (EHR); others may keep a paper record for a set timeframe after or until those claims are paid. Other authors in this publication have written on the importance of our documentation telling the “whole story” for each visit. This is never as important than in a payer audit. Irrespective of the history and treatment plan outlined in the history and physical, follow-up visits must “connect the dots.” Many audits are date-limited. In the past, if a claim was audited, we could include supplemental documentation for the episode of care. These audits are judging each visit as an encounter, and if you are not painting the picture for the reviewer you likely will be denied fees (or have to repay) for that date of service.

What follows is part of an actual audit notification letter sent to this author and colleagues:

Dear Chief Financial Officer:

This letter is to notify you of an upcoming medical review prepay probe for Healthcare Common Procedure Coding System code 99213, evaluation and management (E&M) services. The Centers for Medicare & Medicaid Services requires that Medicare contractors perform medical review to analyze provider compliance with Medicare coverage and coding rules.

We were instructed to send 40 wound clinic records for review. Of those requested and sent, three claims were denied because, according to the reviewer, they did not support medical necessity. After internal review of the records, both wound clinic staff and hospital health information management staff disagreed with the reviewer’s conclusions and appealed all three denied claims. In the end, only one claim was denied. Despite the one unpaid claim, hospital administrators were pleased with the outcome and are on the record as saying that this was “the most favorable audit that they had participated in.” This particular audit was on E&M services, however other wound care services that are bundled with other procedures, including hyperbaric oxygen therapy treatment (HBOT), are susceptible as well. To what do we attribute our successful outcome? These four specific action items can (and should) be incorporated into anyone’s current practice:

(Use the mnemonic WHEN.)

1. W - Write it down. Start your documentation as if each and every encounter will be audited. Did your grandmother ever tell you to “Do it right the first time and you won’t have to redo it”? If so, she was right. If your patient will be receiving a cellular- or tissue-based product, have you documented each item addressed in the LCD? If your patient is starting HBOT, have you scanned supporting documentation into the EHR to demonstrate medical necessity and LCD compliance? 

2. H - Harness technology and use it to your benefit. Use an EHR that allows you to document the clinical interaction and that codes services only on what is documented. In the time of paper charts and dictation we often had to credit charges, as the documentation did not match what the initial charge stated (eg, provider stated he did a “subcutaneous debridement,” but the documentation said he “debrided to the subcutaneous tissue”). Retrospective coding and billing was extremely resource intense. When we made the change to our most recent EHR we were also able to reduce staffing by 1.1 full-time equivalent.

3. E - Evaluate yourself. Conduct regular audits of your patient visits to ensure everything is accounted for.  Make a checklist from your LCDs, then review prior to treatment to make sure each of those have been documented with the required proof scanned into the patient’s EHR. The more work you do on the frontend to be prepared for the audit, the fewer sleepless nights you will incur when it arrives. Preparing for each visit to be audited in advance will save a lot of headaches.

4. N - Never give in. Appeal until you’re told to cease with appeals. Insurance companies do not make money-paying claims. Spend the time to teach staff and providers to construct medical records to reflect the clinical care given (what most clinical staff is trained to do) and support billing. Providers should get paid for the work they do. Spending a little extra time to implement the process will ensure a quick response to the notice of an audit and improve the odds of a successful defense of one’s claims.

According to the Centers for Medicare & Medicaid Services (CMS):

Mission - The Recovery Audit Program’s mission is to identify and correct Medicare improper payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries and the identification of underpayments to providers, so that CMS can implement actions that will prevent future improper payments in all 50 states.

Background - The national Recovery Audit Program is the product of a successful demonstration program that utilized recovery auditors to identify Medicare overpayments and underpayments to healthcare providers and suppliers in randomly selected states. The demonstration ran from 2005-08 and resulted in more than $900 million in overpayments being returned to the Medicare Trust Fund and nearly $38 million in underpayments returned to healthcare providers. As a result, Congress required the secretary of the U.S. Department of Health and Human Services to institute (under Section 302 of the Tax Relief and Health Care Act of 2006) a permanent and national Recovery Audit Program to recoup overpayments associated with services for which payment is made under part A or B of title XVIII of the Social Security Act.

M. Darlene Carey is director of operations of Precision Health Care, Boca Raton, FL. She utilizes metric management to enhance performance and embraces workflow improvement to remove obstacles to success.