Healthcare audits are now occurring frequently. It has become common for state and federal regulators to enforce even the smallest violations, resulting in investigations and monetary fines and penalties. If found in violation, you will not only have to pay fines and face disciplinary action, you will also lose revenue because you will have to spend time dealing with the investigation, instead of practicing medicine.
The adage 'prevention is worth a pound of cure' is definitely true when it comes to healthcare audits. Whether you are trying to prevent Medicare and Medicaid audits, Zone Program Integrity Contractor (ZPIC) audits, or any other kind of healthcare audits, there are steps you can implement in your practice today that may save you down the line.
There are many different self audit systems that you can try. While the development of a formal compliance program is outside the scope of this article, the following suggestions are aimed at helping you assemble a self auditing program that is feasible for your practice.
Self auditing is relatively easy and affordable, especially when you consider the cost of being found in violation by a government agency. The only prerequisite for self audits is having a decent understanding of your coding and billing procedures before you implement the process.
You should begin the self audit process by creating a compliance record committee. The committee will determine most efficient and effective method of conducting chart reviews and the parties involved in conducting such reviews (most likely several physicians).
Physician reviewers don't need auditing experience to make the self audit process successful, but they must never review their own chart and also must understand the basics of good documentation. The Health Care Financing Administration's (HCFA) website provides free, convenient training on topics such as fraud and abuse, ICD-9 diagnosis coding and the HCFA-1500 form.
Once the committee decides who will perform the review, they must also determine at what intervals the reviews will take place. It is best for reviews to occur prospectively, which allows you to correct improper codes before bills are submitted and to correct undercoding before it turns into underbilling, without being flagged by an insurer or government agency. Additional factors to be discussed include how many charts will be evaluated during each review, what the target areas will be, and what standard evaluation criteria should be used.
Outpatient evaluation and management services are major revenue sources in most family practices and should be the focus of coding and documentation audits. Other target areas to consider include inpatient services, nursing home or other health facility visits, and laboratory services.
Develop a chart review form for the reviewers to reference and complete during the self audit. Only the progress notes from individual patient visits should be reviewed, not the entire chart. Nurses and office staff who perform coding and billing functions should also be included in the audit sessions to ensure that the physicians' documentation is linked with the correct CPT and ICD-9 codes.
After a review has taken place, each provider should receive a summary of the review's overall findings, as well as a copy of his or her charts with the reviewers' comments. A meeting should then be held with all members of the practice aimed at making appropriate changes in policies and procedures to correct any errors that were spotted during the review. Additional education may be necessary for those with specific coding errors.
Self audits of medical record documentation and coding can be efficient, cost-effective and educational. Although it takes time to complete, it may save you down the line if investigators show up at your practice.
For more information on self auditing or healthcare audits, visit www.TheHealthLawFirm.com.