Know the key steps to take

The idea of an audit can be an intimidating prospect, but knowing how to respond to one is crucial for even the most careful of practices. With proper protocol, you can dispel any suggestion of billing with the intent to commit fraud or to misrepresent the care provided, which could result in severe penalties, fines, and even prison time.

Here, I discuss the significance of an audit notification and how to best respond to an audit.

Significance of an audit notification

An audit notification, which usually arrives as a letter, provides important information, such as what triggered the audit, what the auditing agency thinks they will find, and the status (beginning or advanced) of their investigation is. The notification will also include what government department or contractor is conducting the audit, and what information or material is subject to it.

Knowing what triggered the audit will give you some idea of what to send in your packet. For instance, if they are auditing the insertion of punctal plugs (68761) you can send chart notes for drop use by your patients. Adding notes of these prior visits to your packet will also show you followed staged therapy recommended by the DEWS II study.

Not all audit requests are as serious as others, depending on what group is requesting it. For instance, a record request from the agency Ciox Health for a risk adjustment audit by a commercial payer probably won’t be as serious as one from the Unified Program Integrity Contractors (a CMS contractor that deals exclusively in the crime of fraud).

How to best respond

Once an audit begins, I recommend you do the following:

• Pay attention to the response due date. The exact date will be dependent on the requesting agency. This is mainly important for risk-adjustment audits by third-party commercial payors.
• See whether you can get paid to send records. With some risk adjustment audits, you can get reimbursed per page.
• Cooperate. Stonewalling will get you a more intense and scrutinized audit that could lead to more severe consequences.
• Never “touch up” or otherwise change your notes or chart. This could lead to dire consequences and a more intense audit, as described above.
• Ensure auditors get all your supporting documentation. For example, if using two-sided paper for your notes, include a cover letter letting them know to check the backs of pages. Also include a list of abbreviations used by your office, and ensure that the writing is legible.
• Follow instructions exactly. Send only what is requested. For paper records, ensure signature authentication via signature log/attestation; for EHR, make sure you comply with CMS’ electronic signature policy (viewable at go.cms.gov/3QppnvJ ), as well as any signature policy your practice has developed.
• Send copies only. If the originals get lost, you can never support your billing and may have violated your state’s record-keeping regulations.
• Keep full copies of exactly what is sent, to whom, and where. If sending a paper copy, send with a tracking number (usually provided by services like USPS, FedEx, UPS), and include a signature. If sending an electronic copy, make sure to get an email “receipt” of the delivery. Save the acknowledgement as proof of the delivery. Must payors will have an online portal where your information can be securely uploaded, which will also include receipt of delivery (if sending by email, make sure you use digital encryption so you are staying within HIPAA compliance). I suggest tasking one person, such as a billing manager or practice administrator, with maintaining these copies and receipts. A tech or medical staff member can be enlisted to clarify some of the documents, if your chosen record keeper is not familiar with them.

Use the results to prepare for the future

As an additional note, during the audit pay close attention to how your compliance strategy is holding up (See “Prepare for an audit before it occurs,” p.46) If there is confusion about roles or miscommunication, or your audit response team struggles to gather the requested information, note it for later. Do not address these issues now, aside from what is necessary to overcome these setbacks.

Once the audit is done and the results are in, review the notes you took during the process. With an audit defense or health care compliance attorney, figure out a way to avoid them in the future by tweaking your audit playbook in ways that only change what did not work, keeping the mechanisms that passed the test.

Finally, understand your rights to appeal. Health care organizations can challenge negative audit results through the appropriate appeals process. The details of that process will depend on the circumstances and the auditing party. OM

MS. SPERRY is an associate consultant for Corcoran Consulting Group, which specializes in coding and reimbursement issues for ophthalmology and optometry practices. Contact her at bsperry@corcoranccg.com or at (800) 399-6565, ext 238.