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Audit Agony: Prepare yourself as insurers look to recoup funds

by Richard Quinn •

Rhonda Buckholtz, CPC, vice president of business and member development for the American Academy of Professional Coders, said she has seen instances in which physicians are not intimately aware of the details of their contract. “Physicians by nature aren’t businessmen,” she said. “In their mind, they know they’re doing the best they can for their patient and they believe what they’re doing is right. And a lot of times, they are.”

But good patient care does not equal good billing. Some advice from Buckholtz:

  • Never throw anything away. Auditors are looking for paper trails when they build a case. To prove that a process was handled in the correct way, the same paper trail must exist in defense of a doctor. In a related vein, do not rely on verbal assurances from consultants reviewing a practice’s procedures. Those comments are viewed much more credibly when put in writing.
  • Consider paying for an independent audit. Buckholtz and others quote examples of health care audits that asked for one level of reimbursement, only to see carriers reduce that number when confronted with an independent audit that shows a practice has followed the rules.
  • Remember that physicians are ultimately responsible for all decisions, even if they are uninvolved in those decisions. “The other thing I find a lot is that when working with the different audits and health plans, a lot of times, the practice managers, coders and billers don’t want to bother the doctor with the details,” she said. “Sometimes it’s that they try to be too helpful or protective of the physician.”

Scott Einiger, a senior partner and director of the New York City Health Law Practice at Abrams, Fensterman, Fensterman, Eisman, Greenberg, Formato & Einiger, said hiring an attorney once an audit has been initiated is often a smart idea. “It’s a very uneven playing field,” he said. “Many of the doctors are ill suited, ill equipped or don’t have the resources to deal with all the things thrown out at them by the carriers.”

Einiger works with some doctors who have become so dissatisfied with the managed-care process that they have opted out of insurance plans. Those physicians, such as the Independent Doctors of New York (http://idny.org/idny/static/home.html), can set their own rates without interference from carriers. However, because most patients rely on health insurance to cover the majority of their health care costs, this option is not viable for many doctors.