Just what is CMS looking for in your records? Most of the time the agency is trying to compare what you have submitted for payment versus what’s in your charts, says Hertz. That is, does your documentation of your patient visits match the services you’ve billed for?
Ideally, CMS would like to see such a match, but missing or improper documentation doesn’t put your practice in immediate peril with the Medicare program, as providers are not legally bound to use CMS’s documentation guidelines.
“The law only requires you to furnish information to show that you provided the service,” explains Glaser. “So billing for something that isn’t charted in the medical record isn’t — in and of itself — fraud … if you provided the service.” Your only obligation is to prove — in some form — that billed services were indeed provided.
Don’t Stand Out
How does CMS choose its targets?
The agency looks for outliers, says Hertz. He explains that CMS maintains detailed statistics regarding “the norm” in each specialty when it comes to coding and billing. If you are an outlier — say you are billing for far more midlevel established patient visits than are your peers — CMS may very well notice and ask to review your files more closely. To determine if this is what CMS suspects, gather your production data that’s under review and compare it to that of other physicians in your group, your state, and the country.
You might think that overall it doesn’t matter much if you tend toward more high-intensity visits than your peers here and there — but au contraire, warns Hertz. That’s because Medicare extrapolates.
“If Medicare asks you for 20 charts and 10 have a particular problem,” says Hertz, the likely response will be, “‘Let’s see — 50 percent of your charts are bad; therefore we need the payments back for half of all your Medicare visits plus penalties.’”
If you do turn out to be an outlier, but there are compelling reasons why, you have the right to submit extra information with your records as justification for your billing, says Hertz.
Also ensure that your informed consent documentation is in order. The informed consent that CMS requires is fairly rigorous; if any of it is missing in your records, that can trigger an audit, says Timothy Kelly, vice president of Dialog Medical, a software company that makes an automated informed consent product developed by a urologist.
“Paying very close attention to informed consent will be to a doctor’s advantage when it comes to avoiding a Medicare audit,” says Kelly, who says he has worked closely with CMS in developing the application.
Truly understanding all of CMS’s rules and regulations is crucial. Some ways to do this include: regularly accessing CMS’s Web site; frequently attending seminars on Medicare rules and regs; and investing in regular internal training for all staff.
An easy way to obtain such training is to purchase access to regular audioconferences on topics like coding, documentation, proper modifier use, and bundling/unbundling. These run in the $200 range, Hertz says, and they allow each staff member to listen in and interact with accompanying PowerPoint presentations. “The more you can educate everyone, the more you can monitor compliance within the practice,” says Hertz.
You can even have an expert come in and shadow each doc, observing how he or she codes and documents over a few days. Then, if you identify problems, spend time working with the doctors whose methods are flawed and could possibly trigger an audit.
“It’s absolutely crucial to the whole medical system,” says Hertz. “It’s just too bad this isn’t taught in medical school.”
