Getting the Most from Your Audit Results
Your practice had an audit, and the results are in, now it is time to ACT! The next steps depend on the specific types of findings. Audit findings typically fall into two broad categories, financial and risk. Financial findings are often the focus of first steps after an audit; however, the risky findings are generally more pressing. Initially the audit results should be reported to a select few to guard against Qui Tam actions.
If the audit findings include the discovery of inappropriate coding practices and associated over payment this finding needs to be assessed immediately. Determination must be made to identify trends and establish how far back the problem existed. You should be able to pull reports from your billing system to ascertain this.
Under the civil False Claims Act (FCA), no specific intent to defraud is required, for generation of a false claim. The OIG has emphasized the importance of dealing with the Federal health care programs with integrity since 1998. It is their premise that all members of the health care industry have a legal and ethical duty to do so. This duty includes an obligation to take measures to detect and prevent fraudulent and abusive activities, including implementing specific procedures and mechanisms to investigate and resolve instances of potential fraud involving the Federal health care programs. Whether as a result of voluntary self-assessment or in response to external forces, if you participate in the health care industry you must be prepared to investigate such instances, assess the potential losses suffered by the Federal health care programs, and make full disclosure.
Contact the attorney for your practice or obtain one to walk you through the process. The information for self-disclosure of healthcare fraud can be found on the Office of the Inspector General Web site. (Health Care Fraud Self-Disclosure | Office of Inspector General | Government Oversight | U.S. Department of Health and Human Services) Store the report findings with your attorney and not in your office. Make certain your compliance plan is up to date and in use. Keep a notebook of all educational activities both in relation to the risky behaviors uncovered in your audit and on going education to cover new coding trends, codes and concepts. Sign in sheets for each educational session should be kept also.
Financial impacts from an audit can show missed charge capture and may highlight inter-office processes that are not netting best billing practices. These should be evaluated and implemented as appropriate. Documented Policies and Procedures to ensure the practices are adhered to are recommended.
Documentation deficiencies are often the highlight of an internal or external audit. These types of findings often result in multiple points of contention. Verify the findings and sit down with the providers to review them. Ask the provider to help you find the missing documentation identified in the audit. Let them conclude whether there is or is not a deficiency. Ask then why the data was omitted and based on the answer discuss the importance of including the missing documentation elements for best practices for patient care and for compliant reimbursement. Providers will have to acknowledge there are problems prior to making change. Change can be difficult in any setting.
Change management must include all of the stakeholders. The providers or a provider representative, a coding representative, a member of the front office staff and back office staff, compliance officer and practice administrator could be brought together in a committee to evaluate audit results and plan for the implementation of recommendations. Implementation may include education, updates to office procedures, updates to computerized documentation templates, updates to charge capture for office supplies and pharmaceuticals, and new and improved procedures for denials management.
A good auditor will make recommendations for improvement with the audit findings. Try those on to see if they are a good fit. If the answer is yes you may want to include them in your planning post audit. Findings that leave you with an unclear view of how to best resolve them should be researched. Network with other similar practices of the same specialty. Some specialty organizations have practice management groups you can access for help also.
Audits are imperative to the health of any clinical practice and the results should be reviewed and acted on as appropriate. Consider them a health maintenance activity that should be done on a regular basis.
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