Payer Audits: Be Prepared!

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Being prepared for the eventuality that you will be audited by a payer, decreases practice stress and the risk of takebacks. Here is a checklist of what every practice should do to be prepared:

1. Make sure ALL of your providers understand coding Best Practices and how the OP coding calculator can and cannot assist you. OP’s Help Center has articles that you should make sure everyone on your provider team reads and is aware of including:

• Coding Basics and the Coding Calculator
• OP Coding Decision Support (Calculator) - What It Can and Cannot Do to Assist You
• Coding and Documentation Frequent Gotchas

1. Know what the audit note is in OP software, how it works and what information is included.
2. Make sure your practice team members understand why and how audits happen. Resources are available on OP’s Help Center:

• Insurance Coding Audits Who and Why
• Insurance Coding Audits What and How

1. Have a regular cadence for internally reviewing your own notes (or providers reviewing each other’s) to build confidence that you will be able to successfully defend a payer audit.

• Ideally this should be done every three months.
• Practices may identify an audit champion who does preliminary work (biller or provider) and decides where gaps in knowledge and documentation need to be addressed.
• Consider using an internal internal auditing tool to “grade” your own audit notes.

1. Make sure whomever processes an audit request recognizes what they are looking at.
2. Have a checklist about what to do next that at a minimum includes:

• Check the response date! (And consider appealing if too short.)
• Who should this go to? (And a second person in case the first is on vacation.)
• Print out the requested notes (AUDIT VERSION) and do your own internal assessment of whether your notes meet the criteria for the CPTs you charged.
• Before you send the payer the notes, consider what else you should send that is referred to, but not included in the note. Things such as Vanderbilts, diagnostic test results (in house and external), reviewed scanned reports, surveys, etc. 
• If you are not confident, consider asking for a broader sample size (but make sure that will help not hurt you). If you have room for improvement, be prepared to explain your team was lacking in appropriate education but you are in the process of addressing it (with a plan for education/monitoring/improvement).
• If they request take backs after your audit: these are often negotiable! Have a plan on who and how you will do it.
• If you practice, are prepared and confident...send them as much relevant information as you have and take pride that you are prepared! Your team did the work, you deserve to be paid appropriately!