Audit Management

If you are like most providers, you’re either afraid of being tasked with a high-volume audit, or you’re tired of being audited year after year. Even though the occasional audit may be inevitable as a practicing healthcare provider, compliance plans and audit avoidance strategies are incredibly effective at mitigating your chances of being audited by payers and CMS.

As new technologies progress more and more payers are actively deploying AI capable systems. This shift is now producing more audits of physicians than ever before and directly contributing to higher rates of denials. Audits take time and resources that you don’t have.  You want to be compensated fairly for the work that you are performing and do what you do best – providing quality care for your patients.

Denials are already costing you

On average, one out of out of every five dollars of revenue cycle management (RCM) expenses are due to denials-related issues alone. They cost approximately $118 per claim to appeal, equating to $8.6B in administrative costs in 2016 alone

Do you know your current denial rate?

Denial write-off adjustments average 3 – 4% of net revenue, which equates to $262B in initially denied claims for healthcare providers annually. 1 in 10 claims is denied at an average 350-bed hospital

When it comes to avoiding an audit there is a lot to consider and every situation is unique. However, here are some tips that can help keep you doing what you do best.

How to Avoid an Audit

Understand your data

Are you an outlier?  Don’t be afraid to ask your coding and billing company to run a report to compare you to other providers of your specialty.

Differences between your billing and that of national averages can be due to inappropriate coding and/or insufficient documentation.  This could cause a loss of revenue in the future, if it hasn’t already.

Know your denial rate

What is your rate of denials?  If you don’t know, this could be problematic.  You can learn a lot by looking at the rate that your claims are or more importantly, aren’t, getting paid.

Overuse of modifiers

A common misconception is that your claims won’t get paid unless you append certain modifiers on them all the time, such as modifiers 25 and 59. However, these should only be used if certain criteria is met, and unnecessary use of these may land you in an audit.

Time is money

Time-based codes are scrutinized – heavily.  Did you submit claims for an excessive number of hours in a day, not just to one payer, but cumulatively?

Do it right the first time

Don’t try to experiment when you are sending in documentation and billing to see what gets paid and what doesn’t.  This can easily end up setting off red flags with payers.

Document it, all of it

Most important is your documentation.  Remember, if it wasn’t documented, it wasn’t done.  You could end up not getting paid for the service. Everything from the completeness of whats documented and how its phrased to simple things like signatures

Where the patient is vs. where you are

Billing for services that are considered “incident-to” still have certain requirements.  If you are on vacation, making rounds at the hospital across town, or somewhere other than physically in the office space, this is an issue.

Under & over-coding

Undercoding (code billed for is less expensive than services documented) and Overcoding (code billed for is more expensive than services documented) are both improper representations of rendered services and could flag you for an audit, whether you’re billing all Level 2 codes or all Level 5s.


You may find it more lucrative to bill for multiple CPT codes, even when a single, more appropriate, code would suffice. However, this typically is a red flag that points to intentional forms of over-coding. Staying abreast of the latest codes used by your specialty helps.

Obsolete coding

Coding and billing professionals are responsible for keeping up-to-date with the changes of code sets such as international classification of diseases (ICD) from the World Health Organization, current procedural terminology (CPT) codes from the American Medical Association and Healthcare Common Procedure Coding System (HCPCS) from the Centers for Medicare and Medicaid Services. Most of these are changed annually.

Knowing your place

Even if you use a coding and billing company or certified coders, at the end of the day, the responsibility lies on you. If the billings tied to your NPI are inaccurate, you could be heavily fined or go to jail.

Get expert support

While you can always make positive changes to the way you document and bill, there’s only so much advice that can fit on a single page. Advize Health has spent nearly 15 years learning the selection criteria and patterns of mandatory audits to better help providers like you avoid unexpected and overwhelming documentation audits. We know how stressful receiving a heralding letter can be. Payers hire us to send them. You’re overworked and understaffed. Your documentation needs to be transcribed. You securely store archived records offsite. We understand what it takes to participate in an audit, and we want to help you plan, prepare, and ultimately, avoid being audited.

Our team of highly trained medical coders, data analysts, fraud examiners, and compliance experts will work with you to devise a customized audit avoidance plan to help you understand your data, your risks, your documentation, modifier usage, unbundling, and more to get your documentation up to audit standards while helping you avoid being flagged for audit by payers and CMS.

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