All right, I am going into provider audits, okay, so auditing your physicians and your advanced practice providers in your practice. All right, so we've got a couple things we're going to go through, tips for educating providers on coding and billing issues, types of payer audits that we may or may not or have received and how to respond to that audit. All right, so again, communication is key. Providers can't change behavior. They can't fix what they're doing wrong if we don't tell them. Don't assume providers have extensive coding and billing knowledge. They are not trained on coding GI, coding and billing in medical school, okay? This is not a class that they have to pass to become a physician. You know, yes, there are some that offer them. There's residencies, fellowships that offer a little bit of, you know, sight into it, but most of the time, you go to medical school, you go through your residency, you go through your fellowship, and it's like, okay, here you go, figure it out, and depending upon where you end up and how many coders they have and experience they have, it might just be solely up to the physician or the nurse practitioner or the PA to figure this stuff out. So again, we can't assume they know all of this stuff. Polling question. What should I do if I get a letter from an insurance company telling me that I billed too many level four visits, level four office visits? Call and argue with them, start billing all level threes, conduct an internal audit sampling of level fours to ensure compliance, start billing level fives. Whoa, 100%, good job, guys. Yes, conduct an internal audit just to make sure you're in compliance. We had this conversation earlier during our Q&A. So just because you get a letter from an insurance company doesn't mean, oh my gosh, I'm in trouble, I can't bill a level three ever, ever again, okay, because that's kind of what they may want you to do. They may want you to kind of get scared. So don't do that, just do an internal audit, document the audit you did, document your findings and you move on. You know, there are going to be definitely variances, and if you if you have a practice that you know what you're doing, or you have coders auditing you, and they're the ones assigning the level fours, that's probably pretty good justification of them. Or you're just again, you're listening to this, this is this training should be part of your compliance plan. All right, so just know that just because you get a letter doesn't mean you need to stop doing what you're doing. Just make sure you're doing correctly. So benchmarking, so we had that question come in about, you know, what the percentage was for level fours and threes. And that's kind of what every practice kind of wants to do a little bit of a benchmarking, okay. So we need to make sure that we know we're kind of in that bell curve. And again, we review, we do reviews, we find potential issues, we train and we move forward. So providers should know if their use of each level of service is in line with benchmarks for their specialty. This is available for purchase, you can go and find the national averages. I would plug that in to run a report in your billing system and see what all levels of service each provider billed for compared to the national average and just see if there's anything that's, you know, sticks out to you. And if so, again, we do that review, double check, make sure we're in compliance. And if we are, great. When the benchmarking or bell curve for a specialty has been determined, a physician's claims for E&M service can be compared to identify those deviations. If the provider or practice is off the benchmark, again, you will see receive letters, you might receive random audits, but that does not necessarily mean you're doing anything wrong. Okay, so here's an example of some of the national averages for GI. And these are for your office visits and some of your hospital visits. So remember, we're around 36% and 50% for threes and fours, and right neck and neck on our follow ups 42% and 46%. So just take that information, plug it into your practice and see what you get. See if there's anything concerning for you. Start there. That's a good audit to start with. All right, so then we've got the outside, knocking on our door, requesting our records, making us work a little bit more, send our records, prove what we got paid for was accurate. So we've got the Office of Inspector General. I'm not going to read this entire definition to you, okay, but they have an oversight of the OIG, the HHS programs. They target hospitals, home health, physicians, chiropractors, ambulance labs, DMEs, anybody that accepts federal money is subject to an OIG review. So Incident 2 and Split Shared, I'm going to talk about shared visits coming up. Modifier 25, we actually got a question that I had answered, a typed answer. We are going to go over Modifier 25. That is one of our top denials in GI. We need to make sure Modifier 25 means I performed a significantly separate visit on the same day as a procedure or other service, okay? So tips later on on how to justify that. Use of Modifier 59, oh, I'm just going to put a Modifier 59 on everything and hope it gets paid. Can't do that. Got to know when it is appropriate to use it. Cloned records, I'm going to talk about that in the EMR chapter, the electronic record talk. Don't do it, okay? Auditors from the payer side are being trained on the quality, not the quantity of your records. They're requesting two and three days' worth of records to ensure we're not cloning. Making sure we bill in the correct place of service. Then we've got the recovery audit contractors, that's another type of audit. And they pretty well look to see what the OIG is doing, look to see what other payers are doing, and they follow suit, okay? So they are contracted. They get paid to find our errors. And here is your recovery audit contractor per region. So depending upon your state, you can go on their website, you can check to see what they are looking at. You can contact them, you can phone them, and you can email them if you ever have questions. Then you've got your CERTs, your Certified Error Rate Testing, okay? So it's to protect the Medicare trust fund by identifying errors at both the national and regional levels. Claims are randomly selected, okay? But definitely respond to them. CERT errors are typically not because the services were not necessary, rather. They indicate a failure to submit documentation or a lack of documentation to support your service that you're billing. These have to be responded to in a timely fashion. But again, I think one big thing that causes a lot of these payers to go and audit a practice is we're not doing what they've asked. They've sent us previous requests and we just put them on the physician's desk and let them get buried. Or we don't know what it is, think it's junk mail and shred it. So you have to know what these reviews look like coming in. There's some published information on Noridian's website regarding one of the issues that the CERT updates kind of came across was, and it was concerning addendums and corrections to your medical record. All right, so you need to make sure that you're doing a legal amendment to a medical record. You need to make sure that you, Kathy mentioned this earlier, we're not, we're not opening a note and fixing it and signing it again. If you sign your record, that is your medical legal document. If you need to add something to it or change something or do a correction, that should be in the form of an amendment. We have to know what the original entry was. So again, these are just different late entries. What a late entry is, what an addendum is. So late entry, additional information was omitted from the original. The late entry bears the current date, is added as soon as possible, is written only if the person documenting has total recall of the omitted information and signs the late entry. Okay, so here's an example. An addendum, so I didn't know it at the time, I have that information now, I'm going to do an amendment and add that information in as part of my document, patient care, etc. And then correction, again, oops, I meant this, didn't mean that, I need to fix it. You know, you've got voice recognition systems, you've got things that are misspelled or again, there might have just been something wrong in there, you're going to strike through it and add the correction, but we have to know what was the original. Corrections of electronic medical records should follow the same principles of tracking both the original and the correction with the current date, time and reason for the change and the initials of the person making that correction. When a hard copy is generated from an electronic record, both records must show the correction. Okay, so we don't make this stuff up. This is in Medicare's guidance. They even say falsified documentation, okay, creating new records when records are requested. Oh my gosh, that's a no-no, don't do that. Backdating, postdating, predating, writing over or adding to existing documentation except as described in the late entry addendums and corrections information. Commercial payer reviews, they're similar to the RACs, to the CERTs, but guess what? There are almost more burden, more of a burden than Medicare could be. I've been into practices where they had stacks and stacks and stacks of record requests from commercial payers. They had to hire someone just to keep up with them. Okay, so they're out there definitely. ZPICs, zone program integrity. You don't want these. These guys are actually investigating fraud, waste, and abuse. They know something was inappropriately done. So investigate potential fraud and abuse from CMS. They conduct the investigation in accordance with the priorities established by the CPI fraud prevention system, performing medical review as appropriate. And often working with the FBI. This is not a random. I want to look at your record to see if you supported a level four. This is, they're going to come in with their potential ammo, their everything, and they can ask you to leave. They can take your computers, your cell phones, et cetera. So if they're involved, that's when you want to be very, very, very concerned. Responding to an audit, again, don't just throw it away or don't just put it on your physician's desk and hope they respond. So these are just routine. So we're looking at the letter, seeing what they want, and then you're giving them that information in a timely fashion. So we don't want to alter our records. We don't want to add something just because, oops, I billed a four and I missed this. So I'm going to add that. You can't do that. You have to send in what was requested. So read your letter. If you get a letter from a payer for an audit, read it. What are they requesting? Include any diagnostic tests, other documents from the chart to support what you billed out. So there was a question that came across in the Q&A that said something about, do you recommend reviewing pathology for your endoscopies? And I said, yeah, that's our best practice recommendation. It's not an absolute requirement, but it's best practice recommendation. Well, if your practice reviews pathology prior to submitting those claims for upper and lower endoscopy, if you get a review from a payer that wants to look at that upper or lower endoscopy and your diagnosis is more specific to the pathology, then send the pathology result as well. Send anything that's going to help defend what you billed. Make sure all records that you send are legible and good copies. Never alter your chart. We talked about that. Copy each page of the record correctly and completely. Make colored copies if you can. Include a brief summary. Include any kind of notes that support why you did what you did, especially if you've got local coverage determinations to reference, clinical practice guidelines, payer-specific things. Keep complete legible copies of all correspondence in every document that you provide. Consult an experienced health law attorney to help you through the audit process. Be prepared to contest the results of the audits. Never accept findings at face value. We've seen that multiple times, where payers request records, we send the records, and they're like, we stand by our decision. Well, go up the chain of command if you don't stand by that decision, because if you don't, guess what? They won. They kept the money. You lost money. So don't just accept your first at face value. All right. And that is it for the auditing and leading a coding team. And now I am going to hand it off to Dr. Littenberg.

provider audits

educating providers

coding and billing issues

payer audits

compliance