How To Survive a Post-Payment Audit – Mike Miscoe


Hello, everyone. My name is Michael Miscoe with Miscoe Health Law and today we’re going to talk about a few tips for surviving a post-payment audit. Now, of course, the most important way to survive a post-payment audit is to not get audited in the first place and that involves profile management, understanding issues that the payers are most concerned about, outside our topic scope for today, we can maybe address that at another time.

But if you get audited, there’s a couple of things that you want to think about in terms of mitigating a potential refund demanded that is likely coming. Understand that if you get audited, it’s not because they randomly selected your NPI number or that they’re doing a completely, you know, lotto type selection as to who they’re going to audit. Usually there’s something in your billing profile that makes you an outlier and suggests to them that there’s potentially money to be recovered, and let’s be clear, I mean, this is … The purpose of any post-payment audit is, you know, while they crow about preventing fraud, waste and abuse, the reality is is that they invest a certain amount of money, they expect a return on their dollar and they generally tend to go after what they perceive to be low hanging fruit based upon your data.

The ways to mitigate some of the potential liability. Obviously if you have in advance studied their medical policies, understand your documentation requirements, their medical necessity requirements, coverage requirements and documented your services appropriately, that’s the best way but to the extent that the record requests that you get from a payer is your first rap upside the head, if you will, forcing you to look at those things, obviously, you can’t change what you’ve done in the past, but as you prepare your records for submission there are a number of things that you can do.

There’s some do’s and don’ts that may help mitigate some of the concerns that the payer might express as a basis for a recovering some of the monies that you were paid.

Fundamentally, you need to look at to the extent possible what the purpose of the request is so that you make sure that you’re submitting records that are responsive to that request. If the request is about the coding or treatment notes, treatment plans, treatment orders, anything that describes and defines the treatment that you performed at each visit in support of the codes that you build those are relevant records.

When you throw medical necessity on a table … Let me back up just a second, in which case the notes that they’re actually requesting are probably what you need to provide and any supporting documentation like I mentioned, treatment plans and whatnot.

If medical necessity is on the table then we have to look beyond the timeframe of their audit request specifically to, let’s say, for example, they pick the year 2018, they want to see all the notes for 2018, fine, but for patients that maybe initiated care prior to 2018 it may be necessary to go back to and provide the initial examination, treatment plan, interim progress evaluations leading up to when the period of review starts so that we can place those visits in context.

You know, to the extent that you can, understanding what they’re possibly looking for, sometimes they come out and tell you, sometimes they don’t, but making sure that you submit all the information that’s necessary to address both, whether your services were coded accurately and whether the services were medically necessary. It’s important to gather those records.

Record organization, I can’t say enough about this. You know, these auditors are people and you want them … You know, I don’t know if like is the correct word, but you want them not to hate you. If your records are poorly organized and you make it difficult for them to find what they need to find, they are not going to like you. Therefore that is going to buy us their audit results. They’re not going to reach and try to figure out your records. That’s not their burden.

It’s your obligation to document your services in a way that they can review them, find what they need to find. If you use abbreviations, abbreviation keys, signature logs, they need to be able to identify who’s signing the records, who created the records, what services were performed and whatnot. You need to make that as easy for them to understand as possible.

Organize your records in ascending date order so that they can read through the record, beginning to end, and find things in the order that they expect to find them. Throw in all your exams in the beginning and then maybe, you know, a series of a diagnostic test results and then all your treatment notes at the end, they’re all out of order and they’re scrolling back and forth through, you know, either a PDF or through paper records trying to figure out where all this stuff fits in and try to make sense out of it. They’re not going to do it and and likely you’re going to end up with the denial and then we’re going to have to sort all that stuff out for them. It makes the appeal process a little more time consuming and expensive.

Signatures, even where payers don’t have signature policies there’s this sort of universal truth rule that auditor’s apply. If the record’s not signed, they’ll deny on that basis alone and they’re keying off a Medicare role, which doesn’t really absolutely require signatures. If they’re missing, they’re supposed to reach out, get attestations. It’s not a valid basis for denial, but nonetheless, they don’t see a signature. They don’t see the provider name under the signature. These are hyper technical things that payers use to deny services.

If your records are electronically signed in your EMR system, fine. Just make sure that it has your name, your credentials at the NDC, whatever additional credentials you might have so that you’re properly identified and it has the statement record electronically signed by and then your name and credentials.

If it doesn’t have that or maybe your system does not permit electronic signatures, in which case your opportunity to sign them physically exists only when you print the records, make sure you sign the records and then we’ll put a cover letter on explaining that your EMR system doesn’t permit electronic signature. We signed the notes physically, you know, when they’re printed, and if necessary, we provide an attestation that the record was contemporaneously created, it was signed when printed, and that solves that particular issue.

With respect to diagnostic tests, you know, x-rays or range of motion studies, physical performance testing, EMGs, nerve conduction, make sure your records identify the order, where that test was ordered and why. Hopefully you have written orders for yourself for those tests. Your report has to exist. If your diagnostic test reports are incorporated into your EMR, that’s fine. Oftentimes payers impose this separate written report requirement that isn’t a requirement anywhere except in their own minds. But it’s something we would address, that the radiographic reports are incorporated into the EMR or the nerve conduction we’ve incorporated those results into the EMR. To the extent that there has to be a report, it can be anywhere. You just got to tell them where it is.

If there are imaging or if imaging is involved to the extent that you can print copies of the images and provide them that is always a good practice. Make sure the images are identified as to the patient, the old lead identification things, that’s kind of in the digital age, those don’t happen anymore, but make sure when you print those images out that the patient identifier and the date the image was taken, that those are all included with the documentation so they’re not confused about who the image pertains to.

Now sometimes when we look at the records some of the big things that payers key on relative to therapy services is that they often will deny on the basis that the therapy services aren’t adequately defined. Meaning, for example, if you’re performing traction, the type of traction, angle of pull, force pounds, whatever, or if it’s intersegmental traction where that’s covered, the area where it was performed, if it was electric STEM, the type of STEM, please do not document interferential because nobody pays for it.

You know, you should be doing other muscle reeducation, reduction of hypertenicity type protocols, but those details should be in the record, not only where the therapy was performed, but how it was performed almost in a treatment order.

Now if your records don’t have that you can prepare an addendum and provide those details with an appropriate attestation that this is how the therapies, these are all the details of the therapies performed.

With respect to therapeutic exercises if you’re billing those, the issues that you need to address there is what the exercises were, sets, reps, weights, hold times, rest times, things of that nature, whether one-on-one contact or was provided and who provided it. Those are issues that they will key on so if that information is not in your treatment notes, we would prepare an addendum to identify all of those things.

If there were … You know, if your treatment plan is a little soft on goals or they’re very vanilla goals, you know, improve joint function, reduce spasm, improve range of motion and increase patient’s capacity for ADLs, you can say that for anybody. It’s not measurable, it’s meaningless to the extent that you can identify more precise, specific goals for that patient either based on outcome assessments, if you were doing them, or just the status of the objective problems. An addendum would be the appropriate place to do that.

An addendum by its very nature is additional information created after the fact and if you’re doing that, make sure that you disclose that that piece of paper is an addendum to the original documentation. You have to identify when it was prepared, why it was prepared, and provide an attestation that the information contained therein is accurate to the best of your knowledge and belief and it should be signed by the treating provider.

Another thing that you can do with addendums is highlight key events, whether it’s exacerbations, dates where there was evidence of significant improvement, changes to the diagnosis, emergence of new problems that maybe caused the care to extend beyond what would be considered normal for the initial condition. Those kinds of things can also be addressed in an addendum, but you don’t want to make it … You don’t want to re-document the entire case. You just want to identify those key points that affected how the patient’s condition ended up being managed.

Signature logs, to the extent that there’s physical signatures in the records or in handwritten notes or treatment logs, initials, you should provide a log identifying who those signatures or initials belong to. Hopefully, they’re all licensed providers so that they don’t raise incident two issues but to the extent that they’re not and they’re qualified auxiliary personnel that you’re permitted to use under your licensure regs, we can deal with those delegation issues if they arise.

Couple of things to avoid since we’re running out of time here, one, never ever, ever in the infiniteness of never ever, alter your records. They are what they are. We can use addendums to explain mistakes, omissions, we can fix those things through addendums, but we need to disclose that this was after the fact created information in response to their request. You can cover a lot of ground with an addendum, but what you can’t do is think you’re smart enough to fix your records and they’re never going to know it because they have really interesting ways of figuring that out and if they become concerned that you’ve altered the records after the fact then what started as a simple pay back the money issue turns into a criminal fraud issue and it’s very difficult to get that horse back in the barn.

Do not alter your records. Resist the temptation. Even if you see an obvious error leave it alone. Leave the records be. You know, any of those issues that we need to address we can address through addendums and cover letters.

Last thing, be mindful of the record submission date. You know, to the extent that you need more time, ask for more time. Usually most payers will give it to you if you have a reasonable basis for the request, staff vacations, the holidays, your computer melted down, something, whatever it was, but if you need a reasonable extension, you can usually get another couple of weeks but you can’t get a lifetime.

What you don’t want to do is ignore the record request so make sure that you train your staff to identify these record requests because any record request should be brought to your attention but the ones where they’re asking for multiple charts, you know, broad number of dates and the record indicates that it’s for something other than a risk adjustment audit, but if you have any questions as to the type of requests that’s being done consult with somebody, get some help, understand what it is, but train your staff.

Do not ignore these things. They do not get better with age because even when you’re non-par they need to be responded to and responded to in time because, otherwise, they may deem everything non-compensable, start recoupment and then it becomes a big mess to try to get that issue resolved.

Those are some quick tips that can help you if you get an audit. Of course, I always recommend you engage healthcare counsel early, you know, that’s familiar with these issues because they can help you with the addendum process and make sure that you don’t trip over your own feet and do something evil that’s going to have bad connotations down the road.

Be sure to tune in next week. Dr. Sam Collins will be on with another interesting topic. Thank you for your time today. Everybody have a great day and a happy holidays.

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