Physician's Practice - November 2008 - (Page 69)

• Who are you? — Even third-party auditors usually make it pretty clear who they are working for. If you just aren’t sure who is asking for information and with whose authority, get help. • Oldies but not goodies — If, postaudit, you discover a payer has extrapolated in a way you find unfair or inconsistent with their own processes, you’ll want to appeal. There was a time when some payers would grab just a few charts, ﬁnd a problem, then assume that every payment for years connected with those codes was made in error. That can add up to a big refund for you to pay. Fight for your rights. GO TO YOUR CONTRACT payers are likely to audit helps you prepare your charts proactively, MGMA consultant Cindy Dunn points out. Moreover, part of good contracting is reviewing these pages so you know what you are getting into before you sign, says Welch. You can try to negotiate how long a payer has — after making a payment — to go back for an audit, and request a refund. Welch says 90 days is plenty. thing all along. “I just came out of one practice,” says Bee. “The manager has had three different audits with three different payers and passed all three with ﬂying colors.” And how you react to the prospect of an upcoming audit will tip the outcome in any number of directions — not all of them good. First and foremost, be nice. Your Although it’s probably in there, always, always, always double-check your contracts if you have any questions at all on whether your payers can legally subcontract auditing tasks (assuming you know where they are — not a given in medical practices). “Go immediately to the contract and ﬁnd … audit rights, scope of the audit, and so on,” advises Welch. Likely, the contract will refer you to the payer’s policies and procedures. You’ll need to get a copy of those. Frankly, it’s good to have the policies on hand even if you aren’t facing an audit. Knowing what and how Most auditors “aren’t going on a safari where they are looking at hundreds and hundreds of charts.” AUDIT REALITY Judy Bee, consultant WHAT ARE THEY LOOKING FOR? Here’s what an auditor is interested in when reviewing your charts: • Service eligibility; • Monetary accuracy (deductibles, coinsurance, plan maximums, etc.); Take time to scrutinize all the clauses about refunds, asking yourself these questions: Can the payer in fact audit you, decide it overpaid you, and just start taking money out of your next checks? It might be best if they can’t take your money until all your opportunities for appeal are exhausted. If you agree, take steps to ensure such language is included in your contract. Extrapolation is another hot button. Say a payer reviews 50 charts, decides you were paid incorrectly, and then extrapolates the ﬁndings, saying you were paid incorrectly for thousands of claims over a six month period. Yikes! Is such heinous latitude spelled out in your contract? Hopefully not. Try to intervene and soften this before you agree to the terms of the contract. DON’T PANIC response to an audit request should be to “gain [the payer] as an ally instead of making them an enemy,” Hausfeld suggests. Instead, “physicians get scared and get worried,” says D’Souza. His advice: Just get the basics and stay on top of things, responding the deadline as you are asked — calmly. Just do what you are required to do and be done with it so you can get back to doing what you love. • Pamela L. Moore, PhD, is editorial director for Physicians Practice. She can be reached at pmoore@physicianspractice.com. READ MORE ABOUT IT! Worried about audits? Let PhysiciansPractice.com guide you. Search “audits” to find: • Cost controls; • Proper use of in-network discounts; • Violation of plan exclusions or limitations; • Provider overcharges; • Level of medical necessity; and • Fraud. WWW.PHYSICIANSPRACTICE.COM If you are audited, don’t panic. It’s not necessarily a done deal, with you left in the ﬁnancial gutter. While audits can reap signiﬁcant money for payers – Medicare recoups about $12 to every dollar they spend in audits, says Hausfeld – you don’t need to sweat an audit if you’ve been doing the right • “How to Survive a Payer Audit” — advice on what coding problems auditors like to look for Audits 101” • More legal advice in “The Law: • Information about Medicare-specific audit practices NOVEMBER 2008 | PHYSICIANS PRACTICE | 69 http://www.PhysiciansPractice.com http://WWW.PHYSICIANSPRACTICE.COM

Table of Contents Feed for the Digital Edition of Physician's Practice - November 2008

Physician's Practice - November 2008 Contents Death of Solo Practice Just a Myth Letters HSAy What? Noteworthy Finding Lost Revenue: The Search for Billing and Coding Gold Getting More: Our Annual Physician Compensation Survey ’Tis the Season to be Neutral Ask the Experts Evaluating Paperless Labs HR in a Box? The Guide Coding Third-Party Audits on the Rise Branding the Cash-Only Practice Intra-Office Tug-of-Wars Stickin‘ Up For Yourself Classifieds Advertiser Index

Physician's Practice - November 2008

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