Posted and filed under Advize News, Medical Record Auditing.

Don’t Stop Believing: Journey. Sweet Caroline: Neil Diamond. Piano Man: Billy Joel.

These are the three top requested dueling piano songs.  What does that have to do with us?  I, Jeanmarie Loria and Eric Rubenstein, presented earlier this week at the exact same time. I would like to report that I had about 100 hundred more attendees than Eric.  I say this because Eric presents everywhere and I rarely present – so it felt good. 

Eric’s topic was Recovery Audits – Attorney Client Privilege. He discussed the role of the Recovery Audit Contractor (RAC), the targeted probe and education (TPE) audits and the use of attorney-client privilege as it relates to internal audits and investigations.  If you have questions or comments about your RAC experience, we want to hear from you.  Email us (erubenstein or jloria at

And the piano, it sounds like a carnival. And the microphone smells like a beer. And they sit at the bar and put bread in my jar. Yes, I do love Billy Joel, especially at The Garden.  While my topic was slightly softer, I still received a lot of questions.  My topic was the Difference of an Auditor vs a Coder.  The bottom line of these presentations is that the results of the audit is what matters the most and that providers should not be a ‘penny wise, dollar foolish’ and seek to save some expenses on third-party audits.

In my presentation, I focused on the fundamental differences between a coder and an auditor.  Beyond healthcare, the history of coders back to Ada Lovelace through Elizabeth Holmes not having an independent audit firm audit her financials for Theranos. I presented that coders provide the input and drive the ‘scarole (the money), while the auditors check for completeness and accuracy. 

I shared my own stories and examples from being both a coder (IT coder) and an auditor (IT security).  I even had to share a picture of my parents for context on how my coding and auditing background was to keep me out of healthcare and then I ended up in the healthcare auditing world anyway.  Sometimes no matter how much you have an internal dueling piano situation internally (I never wanted to do healthcare but then found myself in healthcare), I ended up in the great place where I needed to be.


Here are the outstanding questions I received and some answers, let me know if you don’t agree. I want to hear from you.

  • Any advice on how to approach coders with audit their results? They seem to be very defensive.
    • Help me understand.  Don’t ever make any assumptions.
  • What did you say the yoga auditing does for your group?
    • YogAuditing provides auditors a way of remaining mindful while performing their daily functions.  For more information watch this video.
  • What are the main principles of auditing?
    • Confidentiality, integrity, objectivity, and independence
  • How do you approach a provider that doesn’t want any coding advice and or education?
    • Providers who do not want to listen to, or seek advice on appropriate documentation and coding, are at their own risk for audits, investigations and overpayment assessments.  You can lead a horse to water, but you cant force them to document and code correctly.
  • How many audits per provider per year or quarter?
    • Each provider should be audited at least once per year.  We recommend quarterly, to identify issues that may come up to be able to resolve those problems when identified. 
  • How do manage requirements from different payers? Do you keep a spreadsheet or other tool to keep track of specific requirements?
    • A tool or spreadsheet would be fine as a reference, but typically, Medicare is typically the most conservative when it comes to payment policy, so it may be worth reviewing CMS policies as they compare to commercial, and if the CMS policies are more conservative, it may be better to stay with the most conservative
  • Have you heard of some insurances going to pre-pay audits for certain levels prior to a provider/group failing a post-pay audit?
    • I have not heard of this, but data analytics drives many of the methodologies for audits.