Documentation: Dealing With Audits

While providers fight audits on the legislative front, they need to have a plan for dealing with them.

Of course, in the meantime, providers must contend with the audits in the here and now. That means having a plan and systems in place for working with referral partners; responding to auditor requests; and having the right assets in place when appealing claims — even if there is a two-year ALJ delay (read the main story, starting on page 18, for more information on the delay). Much of this comes down to having the right documentation procedures in place. Here are some key considerations:

Have the right staff expertise.
Make sure that all team members involved in the claims workflow understand all documentation requirements needed to ensure that claims will not raise flags with audit contractors. Staff should also know what is required to respond to auditor documentation requests. Work with internal and third-party experts as needed to train everyone on the team who needs help, and require all claims staff to regularly refer to key reference documents such as jurisdiction supplier manuals to monitor any possible policies changes or new requirements.

Set documentation requirements in stone.
Provider management must set guidelines that require complete and correct medical documentation for all claims. Workflows must conform to documentation requirements, and no claims should be able go past any step in the workflow without having the necessary documentation. More to the point, those requirements must apply to both staff and all referral partners — and the latter group could prove problematic, at least initially. This means providers must work to educate physician staff via in-services and similar opportunities so that those partners understand any changes in documentation policies. More than likely, physician partners and other referral sources will be more than understanding, because they are experiencing the same audit pressures from Medicare, as well.

Leverage information technology.
One of the key tools to help providers make the audit process as smooth and rapid as possible is software. The billing, claims and management systems they have in place often can help providers implement the workflow procedures that will ensure they are collecting all the necessary documentation up front, and that it is formatted the correct way. Also, because billing software houses all documentation electronically, it inherently makes responding to auditor documentation requests much easier. Auditors will stipulate which documentation is needed, and the provider can quickly retrieve it to prove the claim’s validity.

Perform self-audits.
Routinely check claims to determine if they are exposing the business to audits through a faulty or missing workflow step. Claims should be reviewed for missing or incorrectly formatted documentation elements, and if any are found, the provider should be looking for repeat problems to isolate a trend. Here, too, software can help. The overwhelming majority of audits result from data analysis (no small wonder, given that the audit contractors are typically owned by technology companies). So, the reporting tools in software systems can help warn HME providers to analyze their claims to judge their
level of exposure to audits.

Continue pursuing appeals.
While CMS brags to Congress about the amounts of claims it is recouping, it downplays the fact that HME providers were seeing as high as 60 percent of their audits being overturned when brought to appeal. That means providers need to have documentation in place to overturn any recoupments. Sure there might be a two-year delay that could entail massive charges, but the industry is working hard to bring that situation under control. So, in addition to supporting the industry’s efforts, providers must put into place the assets that will help them appeal once the process is restarted.

This article originally appeared in the April 2014 issue of HME Business.

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