Members have advised the Advocacy Council of an issue that seems to be spreading nationwide – audits by insurers of claims submitted by allergy practices for routine services like skin testing, allergy vials, and subcutaneous immunotherapy.
If an audit letter from one of your carriers arrives, don’t panic! It’s not a padlock on the door, but it could be a challenge to your processes and record-keeping – and maybe to your checkbook. An audit is not usually about the quality of care you provide, but the quality of your documentation in your medical chart. Unfortunately, documentation in electronic health records (e.g., electronic signatures) may actually make it more difficult, not easier, to satisfy the demands by the auditors due to the difficulty in supplying the documentation in the manner they require.
Advocacy experts offer the following advice:
Know your contract. It likely includes language addressing audits and recoupments. Be sure your address of record is correct. Commercial payers sometimes threaten to terminate a contract as leverage to settle claims audits. Compare the dollar amount of the claims vs. the time and expense of appeal to the risk of terminating the contract.
Get outside help. Depending on the complexity of the audit, consultation with a health care attorney may be the best course of action.
Any audit should be taken seriously. Payer record requests should be treated as a priority – every member of your staff needs to know and adhere to that rule. Your first interaction with a carrier likely sets the stage for the remainder of the audit period.
Assign your most knowledgeable and competent staff to prepare the submission of the requested documentation. It’s important to include all relevant records, but not anything that is irrelevant. An exact copy of every document included in a response to an audit request is vital. This will make it easier if you need to resubmit records – for whatever reason. If you are submitting from an EHR, this may be a challenge in that you have to print multiple pages. Before you do this, find out exactly what they are requesting.
Meet deadlines – Many audits can be resolved by submitting complete records. Late responses or not responding at all to record requests undermines the credibility of the records and your billing practices. Payers will assume there are no records or records are incomplete. Request an extension if you can’t meet the deadline.
Edits – Never alter existing records. If additional information is needed for clarity or to complete an existing record, an explanatory note is appropriate. Never alter dates in the existing records. If you are requested to supply information for something you do, but is not documented in the record (e.g., route of administration for an allergy shot), you may be able to supply documentation and attest that a change was made with a current date.
Audit additions – during record review, auditors can add additional codes, new issues and/or request more documents.
Duration – Audits can last a long time – several months to sometimes years. Be prepared.
Cross-Plan Offsetting – Know your policy! Reconcile your explanation of benefits to your claims. Some payers will try to recover overpayments from a different plan.
Recoupment – Auditors are sometimes incentivized ($) to find errors and it is highly unlikely that all your records are perfect. Recognize that if your records are audited, you may have to payback something; the goal is to minimize the payback. Be sure to learn from each audit and avoid those errors in the future.
The Advocacy Council’s Billing and Coding Committee is hosting a webinar – Correct Documentation to Improve Clean Claims – Sept. 21 at 7:30 pm CT. Be sure to mark your calendar. More information to follow at a later date.
The Advocacy Council – ADVOCATING FOR ALLERGISTS AND THEIR PATIENTS.
