Protecting Yourself Self-Auditing and Monitoring What Do I Do if Audited? What is a Prepaid Audit Defense Plan? When to inquire about legal proceedings to obtain reimbursement or contest denial?

Protecting Yourself

1. DOCUMENTATION IS KEY!
2. Self-audit and monitor your billing patterns
1. If you bill a five region CMT code, make sure your SOAP notes support all five regions.
2. Make sure your notes support any extra-spinal manipulation.
3. Make sure level five consults meet CPT Manual Criteria ( www.amapress.com ).

Self-Auditing and Monitoring

Audits are most commonly used to review the accuracy and completeness of documentation, coding, and billing records to

1. Protect the practice against submission of claims that could be construed as false and fraudulent,
2. To identify overpayments received from payers or patients that should be refunded, and
3. To identify under coded claims for fear of insufficient documentation and payer audit.

Such billing audits typically take two forms:

1. Standards and procedure review
2. Claims submission process review

Billing audits improperly conceived or conducted can be very damaging to the practice. The OIG sets a basic review guideline of five to ten randomly selected records per federal payer or per physician. These records then must be tested for specific coding and billing regulatory risks. The OIG also prefers that the audits use the same sampling protocol RATSTATS (www.hhs.gov/progrog/oas/ratstat.html) The benefit of using this protocol is added credibility to audit results and reduced likelihood of questioning by OIG.

Alternatively, you may draw 5-10 samples of claims per payer per physician from the universe that you consider high risk in comparison to E and M coding. OIG recommends a typical audit to be performed on an annual basis or upon identifying at least of the following warning signs
1. Significant change in the number/type of claim rejections
2. Payers challenging the medical necessity or validity of claims
3. High volumes of unusual charge or payment adjustments

What Do I Do if Audited?

1. Cooperate with the audit – stonewalling will get you a more intense audit.
2. Don't volunteer information or talk substance with billing auditors.
3. Do not ever “touch up” or otherwise change your notes or chart. Billing Precision eliminates this risk once you have signed off.
4. It is your job to ensure auditors get all of your supporting documentation.
5. Only send notes for the time frame being audited and do not send original, only copies.
6. Avoid the audit in the first place by avoiding the audit red flags. Engage Billing Precision for automatic audit flagging of your claims.
7. Set up a compliance program in your office to ensure proper coding and compliance with laws and regulations.
8. Engage a Prepaid Audit Defense Plan

What is a Prepaid Audit Defense Plan?

1. Many general prepaid legal plans exist but only one deals specifically with billing audit defense.
2. Your malpractice and general liability insurance policies do not cover audit defense legal fees and costs, leaving you fully exposed to audit liability.
3. An audit prepaid defense plan does not indemnify you for any monies you ultimately owe based upon an audit, but provides free and discounted legal defense coverage and financial preventive care for your practice.
1. Initial Audit Consultation
2. Free legal defense for a specified period of time.
3. Extended representation at a reduced fee.
4. Access to top billing audit defense expert network.
5. Annual audit preventive care for your practice in the form of an office billing evaluation and in house seminar on audit red flags.
6. Reduced fee compliance program implementation for your office.

When to inquire about legal proceedings to obtain reimbursement or contest denial?

1. PIP Claims
1. Claim is denied for lack of coverage
2. Claim is denied for lack of patient cooperation.
3. Claim is delayed for investigation for > 60 days.
4. Claim is denied for lack of causation to accident.
5. Further benefits are terminated for medical necessity (either paper review or Independent Medical Examination.
6. Doctor receives less than full payment for lack of pre-certification when pre-certification was done.
7. Insurer down-codes a code billed by the doctor.
8. Doctor receives less than full payment for non-fee schedule codes.
2. Major Medical Claims
1. Request for copies of patient files and/or billing information are received from insurer.
2. Doctor receives audit notice.
3. Treatment is denied as being experimental.
4. Treatment is denied as being outside scope of practice.
5. Insurer down-codes a code billed by a doctor.

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