physician proactive audit

Posted and filed under Providers.

“Providers who may be reluctant to submit a claim for a higher level code, may in fact be taking an overly conservative approach, and submitting claims with a much lower code. “

Recently, former US Attorney for the Southern District of New York and Director of the FBI, James Comey, made some comments relative to compliance, an ethic culture and healthcare fraud.

Comey focused on an ethical culture in the workplace, and billing and coding compliance is a cornerstone of that culture.  There are multiple opportunities abound for fraud to occur in the healthcare world, and those proactive audits work to foster that ethical culture.  We can never stress the positive results that come from such compliance measures.  It is not only ensuring that claims are submitted correctly, but it is also an opportunity for providers to ensure that claims are paid correctly; do not leave money on the table. 

Providers (Physicians) who may be reluctant to submit a claim for a higher level code, may in fact be taking an overly conservative approach, and submitting claims with a much lower code.  Just as important as it is to not submit a claim that is poorly documented for the service, it is as important to submit for the right code to get paid appropriately.  Proactive audits, coupled with provider education, is the way to make sure that this happens.  It really is a two-way street with claims submissions. 

Regardless of the type of provider, the key point our SME’s all say is that if self-audits were done, many of the cases that were civil in nature may never have happened.  Having a third-party do those proactive audits is important; do not let the fox watch the henhouse.  Having retired OIG agents on your side to assist in the process is a very important step in the right direction.  Our subject matter experts can make numerous suggestions as to how to handle an overpayment, and take that extra step to make sure the books and records with the payers are in good standing. 

As we always say, do not be a penny wise to be a pound foolish.  There are costs involved with conducting these audits and reviews, but knowing that the claims submitted are accurate and correct make the process worth it in the long term.