What to Know about Claims Audits from Payers

Increasingly, insurance plans are using the audit process to recoup payments for services which were preauthorized, on the grounds that the chart does not support the coding.  I asked Angela Miller of Dallas’ Medical Auditing Solutions LLC to share some her insights.

Martin Merritt:  What should physicians, dentists, psychologist, psychiatrist and others know about claims audits by payers?

Angela Miller: First and foremost, anything that is not documented, didn’t happen!  The documentation will either win the day or kill your chances of winning an audit.  Perception is key - for example, if the physician is reviewing and not the rendering provider, then the signature line should say “reviewed by,” not signed, as if to give the impression the physician rendered the service.

MM: Can you elaborate more on the examples, perhaps starting with E&M codes for office visits?

AM: Absolutely, the visit chart notes must contain all components used to determine the E&M: History, Exam, and Medical Decision Making.  “Chief complaint” must be the presenting symptoms and should not be “follow-up.”  If a physician reviews the history at each visit, it must be noted that he reviewed the history and there are no changes or this should be pulled from prior visit and noted.  The exam is based on “bullets or points” from each bodily system to count toward each level of complexity.  Every visit may not need to be a comprehensive physical exam.  The medical decision making is a compilation of the current and existing diagnosis, the tests or procedures performed, and what decisions the physician made regarding the patient based on the number of diagnosis, new or old, review of medications, etc.  Again, this all must be documented.  Every visit is not a level 4 or 5, just because the provider is a specialist.  If anything, it is more difficult to get to level 4 or 5 when specialists’ patients are stable. 

In an audit, the entire chart note must be printed and provided.  It is important to read it, double check to ensure all pages printed and pull any tests as well.

Keep in mind all paper and/or electronic chart notes must be signed by the rendering provider.  Medicare provided direction back in 2009 that providers must sign off within two weeks of the date of service.  If the physician does rounds in a hospital, there may have shorter periods required per the credentialing contract just like your commercial plans.

MM: How do tests and procedures affect the providers in an audit? Is there a way for the provider to know if those tests will be covered?

AM:  All tests and procedures must be medically indicated and ordered.   Providers need to not only verify the patient has benefits at each visit, but any special tests, I would recommend speaking to a person to verify they will be covered.    

MM: Where do you see audits going for the future?

AM:  Audits will only increase.  With the added patients onto insurance rolls due to the ACA and those patients receiving care for the first time in years, insurance payer costs are going up. Payers are intent upon cutting costs and that usually means at the expense of Physicians.