Facing an audit? Don't panic
Do these 5 things instead
By David Klein, CPC, CHC

Insurers are getting serious. Since late 2001, they have increased their post-payment reviews and audits and have put greater emphasis on correct coding and documentation.

The increased monitoring and scrutiny have led many providers to feel that insurance companies are out to "get" them. The payors are intent on not paying doctors. The frustration providers feel often causes them to develop an adversarial relationship with carriers and their adjusters, claims personnel, and special investigative units.

Getting angry and confrontational invites defensive (and equally confrontational) behavior. Such behavior not only makes your job harder, it also results in a no-win situation.

Most auditors and investigators will work with you if you work with them. They will make concessions and exceptions if they feel you are trying to be compliant and educate yourself about the rules.

A senior investigator at one of the nation's largest private health insurance companies recently stated his point of view and dispelled the myth that all insurance companies are out to get the doctor. Some interesting points he made:

• Insurance carriers rely on happy clients and employers to renew their contracts every year.

• Carriers want providers to know the rules and do things according to established normal guidelines. If you don't know, ask someone who does. Most coding errors involve a misunderstanding of the rules as a result of bad information from unqualified sources or a difference in philosophy.

• An audit does not necessarily mean the insurer suspects you of fraud, since typically only 10 percent to 15 percent of cases reviewed involve fraud. Before questioning the carrier's intent or validity of an audit, wait to see what the carrier's results are.

• If you face an audit, send records as soon as possible. Long unjustified delays can cause concern about the validity of documentation.

AUDIT? WHAT TO DO

Audits and post-payment reviews can be scary, time consuming, and costly. Often providers feel overwhelmed, and some even begin to question their commitment to the profession.

Avoid the agony and take a proactive approach before you find yourself faced with an audit.

1. Educate yourself. Find qualified, experienced sources for information.

2. Know the coding rules. Improper use of codes and modifiers can make you an easy target for an audit.

3. Document properly. Documentation is the key to justifying and supporting care.

4. Establish positive relationships with carriers. Good working relationships are in your best interest.

5. Get advice. If faced with an audit, always get help. It is imperative you know your rights, especially when settling with the carrier.

A time may come when you need to fight for your rights as a provider and a professional. However, by becoming better educated and developing positive relationships with carriers, you can help protect you and your practice and reduce the likelihood of negative and costly reviews.

David Klein, CPC, CHC, along with Keith Pendleton, JD, founded ProviderPRO.net, a nationally based research and consulting firm focused on advancing healthcare providers in the areas of coding, compliance, and reimbursement. He can be reached at 215-957-1035, dklein@dkcoding.com, or on the Web at www.providerpro.net.