Not sure if you would pass A DOCUMENTATION AUDIT?
FRUSTRATED??
INSURANCE AUDITS are no longer a "rare occurrence" where you hope that 'they' will get "the other guy" and not you.
INSURANCE AUDITS are a part of your contract with your carrier. You AGREED to provide specific information to them. It is no longer an option to ignore this.
INSURANCE AUDITS are a way for insurance carriers to confirm that what YOU, as a practitioner, or your facility, are putting in your documentation is what meets the CARRIER'S guidelines for "Medical Necessity."
There are LOTS of GREAT workshops, seminars, presentations, and expert advisors out there. My personal surveys and conversations have demonstrated that MOST providers HAVE been to at least one (often more than one) documentation workshop within the past three years.
For example:
Over 1/3 (37.3%)* of Chiropractors' notes won't pass an AUDIT due to insufficient documentation which includes determination of Medical Necessity
34.9%* of Inpatient Rehabilitation Facilities will not pass an AUDIT due to insufficient documentation which includes determination of Medical Necessity.
*Statistics from:
No Longer an OPTION not to ACT:
Why individual providers and larger facilities should be concerned about a documentation audit:
In 2017, my office of 17 years was subjected to a post-payment documentation audit and prepayment review audit. Anthem asked for my EHR documentation from 18 months previous, 10 patients for six-months' worth of care, which was over 800 pages. I heard back 6 months later: they contested some billing codes, asked for some money back (a LOT), made some vague comments about notes that "appeared templated", AND...my office was subjected to "PRE-PAYMENT REVIEW."
Here's where the fun REALLY began!
If you are NOT familiar with what "Pre-payment Review" is:
- ALL current and ongoing dates of service are to be submitted on paper claim forms with printed notes, mailed in, and reviewed by the claims department prior to approval and payment.
- EACH DAILY VISIT for every patient that you see in YOUR office is evaluated and held to 100% COMPLIANCE, 100% of the time, on EVERY single carrier requirement or it will be denied.
- EACH DAILY VISIT for every patient will be determined if the services were actually "Medical Necessary"...or not.
SOUND SCARY? If it doesn't, it SHOULD.
If you are an independent office...
If you are a larger healthcare facility...
If you are a larger healthcare facility...
...this will throw YOUR office staff, YOUR office flow, and YOUR mindset into an absolute turmoil, believe me.
If you are a larger healthcare facility...
If you are a larger healthcare facility...
If you are a larger healthcare facility...
...you can be asked for large reimbursements of previously-paid services.