Auditing is important to evaluate the physician processes to make sure their compliance plan is operating correctly and to identify any inappropriate documentation, coding, and/or billing practices. One of the most important reasons for auditing is to identify any potential areas of concern that could put the physician or practice at risk for audits. OIG states self-audits can be used to determine bills are accurately coded and accurately reflect the services provided; documentation is being completed and correct; services or items provided are reasonable and necessary, and any incentives for unnecessary services exist.
Annual self-audits are a good idea. Not only can self-audits clear upcoding and billing issues before payers take notice, but these audits can also help you sort out any lost revenue issues your practice might be experiencing. The number of self-audits could depend on anything from practice size to the introduction of new treatments. And it needn’t be permanent, you might want to conduct self-audits more regularly for a brief period, and then return to a six-month or one-year self-audit gap.
Let’s say your practice just started providing a new procedure or it is offering a new service. It’s important to audit the new service at the beginning, perhaps every 90 days for a period of time. Or if you hire a new physician, the practice should audit after 30 days and then again after 90 or 120. If a practice performs an audited weekly, the findings and issues can then be brought to the managers and provider at weekly meetings.
OIG recommends two types of reviews:
- Standards and procedures review - Are the standards current, complete, or need to be updated to reflect any government changes in regulations?
- Claims submission audits — is coding, billing, and documentation in compliance with payer and government contractors. Are services performed reasonable and support medical necessity?
Steps to develop & comply with OIG self-audit requirement:
- Determine who is accountable for specific roles within the organization
- Assign a strong coder who can review the medical records and bills for accuracy of the information from coding
- Accounts Receivable/Payable work to confirm the charges are accuracy for services billed
- Medical Records verify the medical records are complete and all diagnosis codes are documented and are currently being treated
- Set a time frame: The OIG recommends quarterly audits
- Determine the number of charts to by reviewed
- Specify the types of accounts to review. For example, for outpatient accounts you should: Review ICD-10 codes; Review charges (important for potential overcharging or missed revenue), and; Review providers level of care and does their documentation support the level selected
- Reports should include all your findings: the good, the bad, and the ugly. Included educational resource so the coder and provider can improve the accuracy
- Meet with the coders and provider to go over the results and office education pointers.
Additional guidelines:
- To flag down any potential compliance issues, everyone involved in coding and billing should be on alert for potential problems. Every employee should be tasked to look for red flags to indicate a potential problem. Problems should be brought to the attention of a designated manager. If you want to go this route, be sure to appoint a compliance manager who is charged with investigating reports of ‘red flags.’
- If you don’t have enough coders that you can successfully have all the work audited in-house, we recommend that you hire an outside auditor, or have someone in the office who is aware of coding perform the self-audit.
- Even though they might take some time, self-audits can only help the practice. Self-audit carefully, and you can launch a preemptive strike on coding and billing problems – before they become the stuff of nightmares.
Medical Billers and Coders (MBC) has certified medical billers and coders who can assist you in self-audits. We can help you to design the self-audit program, its execution, and implementation of takeaways into day-to-day billing practice. To know more about our medical billing services you can call us at 888-357-3226 or you can write to us at info@medicalbillersandcoders.com
