How to Prepare for Your Pending Audit

Receiving an audit notification letter can be very unsettling for any healthcare provider. Successfully navigating the process begins with appropriate preparation. This article will help your chances for audit “success” by offering a guide through the preparatory stages.

You start the practice day off just as you would any other day: The mail arrives to the wound clinic around 11:30 a.m., but one thing that stands out from today’s stack is a nondescript envelope that looks different than an explanation of benefits from the Centers for Medicare & Medicaid Services (CMS) that you’re accustomed to. Still, this looks like “official business” in that it’s addressed from a federal governmental agency. ... And so the auditing process begins with the dreaded notification letter. Yes, you’re being audited. Now what? This article will help to answer that question as well as the many follow-up questions to be expected.

Responding to an Audit Notification

It is important to respond quickly to audit requests, which may allow, for instance, 45 calendar days or 15 business days from the date on the audit letter (not from the date you receive the letter) for practice managers to submit either a request for an extension or the records being requested. Don’t delay in responding, whatever the deadline may be.

If there’s a payment being requested and the amount is small enough, providers may want to consider paying that bill immediately. If and when an auditing case is reversed, any paid money will be refunded. This approach also helps providers to avoid potentially enormous interest penalties that can accumulate should one challenge an audit case, not pay the money up front, and lose the decision. After responding to an audit an “audit coordinator” and a team of professionals within the wound clinic should be identified to handle all paperwork and communications involved throughout the auditing process. The audit coordinator is someone who will be the focal point for all audit activity while helping to manage and oversee internal processes. Team members to consider should include those who are likely to impact the audit process, such as coders, business office staff members who may receive denials, staff members who review records, and clerks who process or copy charts for each request.

If an extension is needed, simply request one. Do pay attention to the deadlines on this particular issue, however. Alert the practice’s attorney and review all necessary documentation to begin building a defense, if needed, to show that a compliance plan was followed while citing such references as CMS 1995/1997 documentation guidelines, the Medicare Claims Processing Manual, ICD-9/ICD-10-CM, and Current Procedural Terminology coding guidelines. Review all charts before submitting them to a carrier. Be certain that everything that could support your claim is included.

A cover letter that explains the patient care rendered and any additional information that was included within the documentation to support medical necessity should be written with the assistance of the attorney. Send all documentation with a return receipt requested to ensure proof of delivery and the date delivered.

Preparing for the Audit

Make copies of everything being submitted so that a thorough review of materials can be conducted with the attorney, who should also receive copies of all submitted documents. Make sure all pages are accounted for. Numbering pages submitted will help to track all documents.

Do not make any changes to any records, but if you find things that are available in the record that were somehow not documented as clearly as you believe, explain this with a cover letter or with additional documentation noting why there is a separate entry being made.

Develop an audit database to track all letters received from the auditing body to prevent loss of communication and/or missing of deadlines. (Only send documentation for the dates of service requested.)

If a decision is made to eventually appeal the findings of an audit, the provider must complete a CMS redetermination form and submit it to the CMS intermediary. (Five levels of appeal are available — with the supporting documentation necessary — and should be filed as soon as possible.)

Often, acting immediately and preparing a solid defense for one’s billing can produce better odds that the case will be ruled in one’s favor if coding has been done correctly.

An attorney and designated individuals should attend and represent one’s practice if the reviews are performed in person. The attorney should know the regulatory guidelines for the time period of the audit and the clinician/manager with medical knowledge of the record in question should be able to provide insights into all records themselves.

Dr. Barbara Aung is certified by the AAPC as a medical auditor and a surgical foot and ankle coder. She's a member of the American Podiatric Medical Association’s coding committee and is a published author and national lecturer on topics related to documentation, coding, and billing. She has maintained a private practice located in Tucson, AZ, for more than 20 years and is a panel physician at St. Mary’s Wound Center - a Healogics facility - in Tucson.