Audit Agony: Prepare yourself as insurers look to recoup funds

Another option that helps to protect against audits is to band together in shared-services scenarios sometimes referred to as independent practice associations. The arrangements may require approval by state officials, but the advantage of physicians working together is “bargaining clout,” Einiger said. Many physicians quietly grumble that insurance carriers prefer to target smaller practices because they are less able to fight back than the larger institutions. That argument can be mitigated when practices remain individual for medical purposes but share risks and services such as supplies or electronic medical records (EMRs), he added. Dr. Wanamaker also urged physicians not to be cowed by a carrier just because an audit has been initiated. At that point, carefully review the audit parameters to ensure that the practice is being treated fairly. “Before you let them in the door, as best you’re able, agree up front what (they’re) looking at, even if that’s a phone call to your local medical director,” he said. “Box in the scope of their investigation.”

The last time Dr. Wanamaker’s practice was audited, the question was whether bilateral procedures had been correctly billed and paid. “We asked for the list of patients they had questions on,” he recalled. “And we looked at it first, and we found that a third of the charts they wanted to look at fell outside their allowable scope of inquiry. The first thing we did is we went back to them and said, ‘This chart, this chart and that chart, you’re not allowed to look at this.’”

Of course, the best defense for any audit is to be doing the right thing. And whether that’s accomplished via the hiring of an accredited coding expert to ensure a practice’s compliance or keeping an attorney on retainer to help implement procedures for that compliance—if an audit can’t find a mistake, then the issue is moot.

“First, of all, you have to do the job properly,” Dr. Wanamaker said. “You may not like the rules, but the rules are what the rules are. You have to follow them.”