Just when you think your practice is running without a hitch, it happens. You receive notice of an audit from one or more of your payors, demanding detailed records on one or more of your patients—their beneficiaries.

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No one welcomes the distraction from clinical care and additional work that an audit requires. That having been said, you need to take these audits seriously, according to AMA Senior Adviser Kathleen Blake, MD, MPH.  

Dr. Blake discussed the challenges of payor audits and how to prepare for them during a recent episode of “AMA Moving Medicine.”

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Most audits are not really about how well physicians practice medicine, Dr. Blake said.

“They are usually not talking about the quality of the care you've delivered. What they're talking about—what they're interested in—is did you document in the chart in a way that supports the billing that you submitted to either the government or to the commercial insurer? So, you have to take, quite honestly, a bit of your ego out of it,” she advised.

Physician practices also should engage their own business resources in preparing for an audit and meeting audit deadlines. The vast majority of physicians don’t have the legal and accounting skills to manage the audit process, she noted, and practices often rely on their attorneys, accountants and others, including coding and billing experts, to meet audit demands.

“Most audit requests come with a timestamp on them, and the clock is ticking,” Dr. Blake said. She recommended practices start responding to the audit demands immediately and do their best. If practices need more time to comply, they are more likely to get an extension if they have shown a good-faith effort.

The AMA Payor Audit Checklist (PDF) helps practices respond effectively to payor records requests while minimizing the administrative burden associated with responding to such requests. A thorough and timely response could reduce the likelihood that a practice will have to return money to the payor, pay a penalty or lose access to the plan’s beneficiaries. 

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Governmental and commercial insurer audits each have their own requirements.

Medicare and Medicaid audits are managed by the Centers for Medicare & Medicaid Services, which has developed unique but consistent approaches. “They now use what's called a targeted probe-and-educate process,” Dr. Blake said. That bureaucracy places a heavy burden on private practices and their recordkeeping.

“Take it seriously, because the audit contractor will come in, they will work with you to go over your records,” she said. “They will ask for more and more records, and then it's their job to educate you on how to do a better job with documentation. And this oftentimes goes through several cycles. Take it seriously the first round.”

Commercial insurer audits are more traditional, but their audit practices are less consistent—defined individually in each contract.

“There may be different triggers. Increasingly, we're hearing that commercial payors especially are using artificial intelligence tools to be able to see if you are becoming an outlier, and you really have to look at the rules and the requirements to be able to get it right. What works for one payor really may not work for another,” Dr. Blake said.

Physician involvement in the process is essential, she added.

“The first thing you have to look at is the medical necessity of what you did. And you have to make that the starting point responding to a request, including what documents will support that decision—that medical necessity and level of complexity, and that perhaps other procedures and tests were needed,” Dr. Blake said. “Only a doctor can do that. And ideally, it will be the physician who delivered the care. And so, you cannot delegate this task.”

AMA Moving Medicine” highlights innovation and the emerging issues that impact physicians and public health today. You can catch every episode by subscribing to the AMA’s YouTube channel or the audio-only podcast version, which also features educational presentations and in-depth discussions.

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