We Know What The Auditors Are
The answers to your audit questions.
The single most costly issue facing all medical practices is an insurance audit.
Practices are completely unprepared for an insurance audit. Nteon Practice Consultants can protect you and your practice from these costly insurance audits.
What are the chances of being audited?
Risks of an Audit are High and Getting Higher!
· All payers have increased the number of auditors and the number of audits!
· Medicare, Medicaid, and all commercial payers have been instructed to review claims from previous years to recover reimbursement previously paid.
What is the Insurance Audit Process?
· Once a practice is selected, prior to the audit, the auditors review your claims looking for issues.
· This is never a random selection. The auditors want to make sure the records selected will result in denials.
· With this "suspect claims" criterion, they select a set of patients. Between, 20 – 100 patients.
What are the Auditors Looking for?
· They are looking for any missing or incomplete information. Any reason to deny the exam or procedures.
· Recording of History, ROS & Meds: Many practices refer to previous exams or pull forward.
History must be documented in full for every exam. This is a common cause of audit failure!
· Many EHR systems do not document compliantly despite the doctors best efforts. Doctors mistakenly believe they are compliant and lose an audit.
· The auditors are familiar with these EHR deficiencies and use them to deny the exam.
What Are My Chances of Passing an Audit?
· Because of the process an average of over 90% of practices audited - Fail!.
· "I have a Peer Review." Unfortunately, most of your peers are not aware of current compliance requirements.
Most Peer reviewed exams fail an insurance audit. Peer review is no protection!
· Almost all doctors who fail an audit are shocked because they felt they performed a good examination.
· Auditors are looking for technical compliance issues, missing information, no matter how minor!
· They are NOT looking for a good exam!
· After losing an audit, practically everyone is stunned. They documented their exams the way they were taught; the way their EHR system works, a full exam. But the auditors are looking for technical compliance.
· Many doctors say they do comprehensive exams and are not worried. Then they are audited and lose.
· The auditors do not care, they look for any reason to deny the exam.
· Finally, look at the reasons for failing an audit. Be honest with your self. If you are in the 90%, you will fail!
How High Are the Penalties?
· The auditors apply the failure rate (typically 90%) to all the reimbursement paid to you over multiple years.
· This is referred to as “Extrapolation”. The auditors then add Interest and Penalties to that amount.
· In the last year, we have seen typical penalties between $150,000 and $225,000. Solo Practitioners.
· We are currently assisting a 2 doctor practice penalized $1,500,000 and another for $1,800,000!