Surviving Common and Costly Audits

by Robert Rebello, President, EyeCor Nteon
reprinted by permission

All of the insurance companies have significantly increased their audits. One of the major reasons is the average penalty for a negative insurance audit is between $100,000 and $200,000! When you do the math, with only ten audits, they make $1,500,000! With the number of practices the insurance companies audit, this results in more money than can be obtained in fee cuts!

To ensure an increase in their audits, the companies have increased the number of auditors. Some audits are random and others are a result of information provided by the practice through a request for records. Some insurance companies schedule audits in advance. Others conduct surprise audits.

Nteon Practice Consultants, performs "pre-audits" for practices across the country. A "pre-audits" will assist in ensuring your practice would survive an insurance audit, thus avoiding a severe financial penalty. Consistently, most practice owners say they are sure their exam documentation is compliant and want our pre-audit just for "peace of mind." Occasionally, practices admit their documentation is non-compliant. Unfortunately, we find most practices are non-compliant! If audited by any of the insurance companies they would have been assessed significant penalties.

Reasons for Negative Audit Findings

As a result of our pre-audits and helping practices that have been hit with an insurance audit, we see the most common reasons for a negative insurance audit.

For paper exams the most common reason is poor handwriting. Most doctors who have paper records do not fully comprehend if the auditor cannot read the documentation you will fail an audit. The auditors will not take your word for what your records have.

Another important observation is that (except for poor handwriting) there are more compliance issues with EHR systems than with paper records. There are two primary reasons.

One major and common problem is that a printed report does not contain all the information the doctor has recorded in the EHR system. Insurance auditors rely on print outs of exam documentation. When the auditors review printouts that are missing exam documentation, depending on the amount of missing information, this will result in severe negative findings only because the EHR did not print the report correctly! Even if you get this reversed, it will cost you time and money for the appeal process.

Make sure your printouts contain all of the information in your exam record. If not contact your EHR vendor immediately to have it corrected. Do not wait until you receive a request for records or when an auditor shows up at your office!

Another problem is the usage of non-compliant templates. In most, but not all, cases the templates supplied by the EHR vendor has most of the required information to pass an audit. One problem that arises is when the practice changes the templates to make it look more like their paper charts. Unfortunately, as a consequence of these template changes, required
information is frequently eliminated. This results in noncompliant exam documentation and failed audits! We also find cases where the default templates supplied by the EHR vendors are not compliant.

By far the most common problem for Medical Exam documentation is missing or incomplete patient history, Review of Systems and History of Present Illness (Chief Complaint). There are specific minimum requirements for each of these. Most EHR systems do not verify the minimum amount has been entered. This results in finalizing of non-compliant exam documentation!

Top 10 Reasons for Negative Audit Penalties

• Missing or incomplete HPI / Chief Complaint
• Cloned Records – EMR Systems
• Missing or incomplete Interpretation and Reports
• Paper Records – Illegible records
• No documentation “Initiation of Diagnosis Treatment”
• Insufficient Patient History (PSFH)
• Insufficient Review of Systems (ROS)
• Insufficient Exam Elements
• Diagnosis Inappropriate or not Supporting Exam Level
• Medical Decision Making not supporting Exam Level

Take Audits Very Seriously We still hear from doctors where they do not believe audits are as common and serious as they are. A doctor that had been in one of my lectures and thought I was exaggerating. Later he was audited and hit with a fine of over $100,000! He said he wished he believed me.

Please take this seriously. I have heard from too many doctors trying to figure out how to survive a negative audit where they have been hit with high penalties.

For more information on how to avoid a negative insurance audit, contact Nteon Practice Consultants.