Posted and filed under Fraud, FWA, Healthcare, Medical Record Auditing.

Healthcare providers have a lot on their minds. Between daily rounds, patient care, and an ongoing global pandemic – it’s not easy to stay on top of administrative tasks like documentation and medical record maintenance. Even so, medical record review is a critical function of the healthcare ecosystem. The reality is that there are a lot of fraudulent claims being submitted annually ($68 billion), and unscrupulous actors aren’t just putting money in their pockets – they’re diminishing the quality of patient care while driving up the overall cost of healthcare.

It’s also true that incorrect claims are submitted all the time without the intent to commit fraud. These kinds of preventable documentation errors occur far too often, tying up revenue and putting practices at risk of fraud, waste, and abuse charges. The journey to becoming a compliant, audit-proof practice is a long road that will require some systemic changes and even retrospective analysis of past documentation behaviors, but there are some fast and easy ways to avoid fraud charges and perfunctory payer denials.

Here are 3 ways to clean up your claims documentation practices and avoid a targeted audit.

Know What Payers Are Looking For

There are certain codes and modifiers that payers and CMS scrutinize more heavily than others. For years now, there’s been a longstanding myth that claims won’t get paid unless certain modifiers like 25 and 59 are appended. This is not the case. Overuse of modifiers is a red flag, and the unnecessary overuse of them could put a target on your back. Document thoroughly and honestly when applying these modifiers to your claims. The same can be said for time-based codes. Payers are paying attention to the number of hours in a day. Do not exaggerate your workday or patient hours. Excessive use of time-based codes can put you on the fast track to Audit City.

Advize Health offers audit & advisory support to provider practices, clinics, hospitals, and other healthcare facilities. Need help? Contact us.

If It Wasn’t Documented, It Wasn’t Done

Documentation is your most valuable asset in avoiding audits and acing them, should you come under random review. Maybe you’ve been lenient in your documentation practices before, but it is never too late to clean up your act. Do not perform risky experiments to see which claims get paid or rejected, and avoid documenting the bare minimum. Record every aspect of patient interaction to ensure you get paid for all services rendered; nothing more and nothing less. Pay close attention to phrasing, and sign off on all required forms before signature-related denials happen. Why do tomorrow, what could be done today?

Get Educated 

Physicians and office managers have a lot on their minds. New procedures, new regulations, new codes, new exceptions to longstanding rules…the list goes on. It’s unreasonable to expect that you can stay abreast of all the information, all of the time. This is where continued education becomes a vital part of your audit avoidance strategy. Identify the weaknesses in your team’s knowledge base and commit to participating in focused training by experts in the field. Whether it be Evaluation and Management, modifier usage, split/shared services, OIG and CMS warnings, or compliance, you can receive extensive education that will give you and your team the tools required to avoid and ace any audits that come your way.

Advize Health offers on-demand training for medical coders and auditors. To browse the course catalogue, click here.