April 2016

April 2016

Q: When an audit is a good thing.

A: When it’s an internal audit that you’ve initiated.

Why would you undertake something so time-consuming? The more relevant issue is what could happen if you don’t. Error-riddled and/or incomplete documentation can cost you in more ways than one. Not only can it affect your reimbursement from third-party payers, it can also affect your licensure.

An internal audit for documentation can help determine if:

  • Risks are appropriately identified and managed;
  • Significant billing, coding, documentation, and other financial and operational information is accurate, reliable, and timely;
  • Employees act in compliance with policies, standards, procedures, and applicable laws and regulations;
  • Internal standard operating procedural programs, plans, and objectives are achieved;
  • Quality and continuous improvement are fostered in the practice’s record keeping process; and
  • Significant regulatory issues affecting the practice, such as documentation requirements and other Medicare standards are recognized and addressed.

Begin with an initial audit, generally called a baseline audit, before any compliance program is put into place. Then, create a list of significant goals for improvement and a time period in which to achieve those goals.

When auditing your documentation, begin by looking at Medicare guidelines. Medicare has set forth the documentation required for initial and routine office visits. Measure yourself against these standards as you review files from each payer class.

This may not be a lot of fun, but it’s important and necessary. The risks of not self-auditing are high. Insurance carriers are beginning to routinely file complaints with examining boards when a doctor’s documentation doesn’t meet their contract’s requirements.

Don’t find out the hard way. Set up a regular schedule for internal documentation audits. Uncover the trouble spots before an outside auditor does.