Take this step to avoid penalties and corrective action processes with insurers
I had a casual conversation with a person who regular-ly performs CMS, medical record and documentation audits for eye care health services, during which I asked: “What are the most common areas that we, as eye care providers, tend to score poorly on in the audit process?” (See “Top Five Problem Areas,” below.)
Among them: Failing to annually perform self-audits, which allow problems/errors to be discovered internally, and then providing internal, written documentation to show how problems are being found and addressed proactively.
In this article, we will review self-audits in detail and discuss ways we can improve them. Put simply, “improvement and compliance” means, if audited, we score well! This, in turn, means we avoid penalties and relegation to corrective action processes with insurers.
TOP FIVE PROBLEM AREAS
1 Failing to participate in provider education to stay up-to-date with best practices in billing and coding compliance.
2 Failing to routinely (yearly) perform self-audits that allow problems/errors to be discovered internally and then providing internal, written documentation to show how problems are being found and addressed proactively.
3 Failing to document patient’s chief complaint (detailed explanation of the visual complaint or problem).
4 Failing to document history of patient’s present illness that expands on the chief complaint.
5 Failing to document detailed communication with other providers.
WHAT IS A SELF-AUDIT?
Let us begin by discussing the self-audit. As always, I will provide you with a link to a resource from the source, CMS: go.cms.gov/2WNVXtE .
According to CMS: “A self-audit is an audit, examination, review or other inspection performed by and within a physician’s or other health care professional’s business. Self-audits generally focus on assessing, correcting, and maintaining controls to promote compliance with applicable laws, rules, and regulations.”
The purpose of a self-audit is to review a sampling of patient records to identify areas of non-compliance with applicable coding, billing and documentation requirements. Once these areas of non-compliance are identified, the practice can then document its findings and the corrective actions taken to ensure future compliance.
STEPS TO TAKE
Here are the steps that should be taken to perform self-audits:
- Designate a staff member who knows the rules for documentation and coding to review the records. Note: Physicians should not review their own records.
- Pull a random sampling of the past three months, including five to 10 charts for each insurance plan for each provider.
- Use a checklist, if provided, by each insurance plan to look for accuracy in documentation and coding.
- Provide the results of each audit to allow the provider time to perform corrective action.
- Utilize the results of each self-audit to then target ongoing monitoring and self-audits.
If the self-audit identifies areas of overpayment or possible fraud, it is imperative that the practice self-disclose the information and return any overpayments immediately. Each insurance plan has a different process for self-reporting. As such, optometrists should obtain and follow each of those specific guidelines. Self-audits and self-disclosure is important, as they can mitigate the practice from risk of running afoul with the False Claims Act and laws that punish providers severely, including exclusions and punitive corporate integrity measures. OM