It's a workday like most others. Your waiting room is full, the staff is harried, and you are 30 minutes behind schedule. Then your office manager alerts you that she has received notice that Medicare is auditing your practice.
Think this can never happen to you? Don't be too sure. Medicare investigations and audits of physician practices are commonplace. In fiscal year 2002, the Office of Inspector General (OIG) excluded 3,448 people and companies from Medicare/Medicaid reimbursement, and secured 517 criminal convictions and 236 civil actions. Further, private insurance companies are now pursuing physician practices through what they, too, term "audits" and "fraud investigations."
While these payers have the right to collect on incorrectly paid funds, they lack the authority of a government investigation. Check your payer contracts to see what authority private insurers have in this arena before you respond to a letter from their "fraud unit."
If you are notified that your practice has been selected for an audit, don't panic. Medicare and other third-party payers frequently conduct reviews and audits for a variety of purposes, such as when a practice enrolls for electronic billing. Read the notice carefully to see if it lists the type of review or audit being performed or the reason your practice was selected for the investigation. If a private payer has initiated the review or audit, look in the company's billing or provider manual to see if any information is listed regarding their right to audit your practice and the types of audits that may be performed.
Check Medicare's or your local carrier's Web site for additional information. You should also check the Office of Inspector General's annual Work Plan for the current fiscal year. This information can be accessed free of charge from the OIG's Web site, www.oig.hhs.gov.
The Work Plan describes the current priorities of the OIG and may help explain why you were selected for review.
Hire the right help
Contact your attorney as soon as you become aware that you are being audited. Your attorney should guide you through the audit process; don't make the mistake of going this alone.
To start preparing, have all of the affected charts pulled. Make sure all information has been appropriately filed and that no information is left in the chart "filing bin" in your office. Whatever you do, do not under any circumstances start making changes to the medical record, even if you think the additional information would be helpful to the reviewer.
Your attorney may likely recommend retaining the service of a qualified coding consultant to review the affected charts. This is money well spent. It is a good idea to have an unbiased opinion regarding the accuracy of the coding of the charts that were selected for audit. A coding consultant may also be able to identify trends in your coding that may have subjected you to review in the first place.
For instance, your practice may bill an exceptional number of professional services as level 3s, for fear that coding at level 4 will make you subject to scrutiny by auditors. Knowing potential coding problems in advance may help you mount a successful defense of the audit. There may be supporting information in your practice that justifies your coding that you can then, with your legal counsel's approval, provide to the reviewer.
A coding consultant may also help you identify other problem areas — such as lapses in documentation, incomplete histories, and illegible charts — and offer you guidance regarding how to prevent such issues in the future.
It makes a substantial difference who hires the coding consultant. If your practice does the hiring, then all reports and other materials generated by the consultant are subject to discovery, whereby the government may demand to review materials such as documentation and consultant reports. If you have hired the consultant you have no legal right to protect that information. However, if your attorney hires the consultant as part of his or her legal advice provided to your practice, the consultant's findings may (but are not guaranteed to) not be subject to discovery.
Submitting your documents
Your attorney should assist you in putting together the records to be sent to Medicare or the applicable third-party payer. Most attorneys recommend that you only provide the information requested in the audit letter. However, you need to look at each chart in its entirety. Your attorney may decide to forward additional information from the chart that supports your coding.
