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4 Reasons Why Provider Audits are Necessary

“Get a free scooter!” You may remember those words uttered on a commercial that ran continuously a few years back. In August of 2014, the Washington Post broke a story on how the government paid billions of dollars for Medicare recipients to get a free motorized wheelchair. The perpetrators of this scam were intentionally defrauding the government by using loopholes to make huge profits on markups for these chairs.

The wheelchair scam example is an outlier, but it is what most people think about when the topic of fraud is brought to the forefront, but that is just one high-profile case. There are many instances of unintentional errors that can occur due to lack of understanding of the many regulations and nuances of medical billing. Consider auditing your providers for compliance and finding opportunities for improvement.

Here are 4 reasons why:

1. Billing Mistakes: still the provider's problem

You may have recently read the headline about the $250,000 typo that was narrowly avoided by a NY cancer center. Billing mistakes can and will happen, but it doesn’t matter who actually made the mistake. The provider still takes the responsibility for every claim billed out under his or her name and license. Consistent coding compliance audits and process checks on the billing will ensure that mistakes are minimized and corrected in a timely manner.  

2. What your providers don’t know will hurt them

Each provider is expected to keep abreast of any changes to the law and healthcare billing processes as they arise which can be incredibly difficult. Providers may think they are safe because they are not intentionally doing anything out of compliance, but they are ultimately responsible for codes submitted and charges billed. . A compliance audit will catch and give the opportunity to correct any mistakes that may be unintentionally occurring.

3. Technology may add to the compliance confusion

Your patients each have individual and different concerns and needs, but technology doesn’t allow for that degree of individuality sometimes. There is a cloning feature in most EMRs so the provider can reuse the same note over multiple patients. While it may save a lot of time on charting, especially for similar diagnoses,  this can be a disservice for the patient and cause compliance issues. No two patient visits are exactly the same so the provider must take the time to update the documentation to reflect each visit. Completing an external audit where an outside party reviews the documentation to ensure that all guidelines are being followed is a worthwhile investment.

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4. Unintentional errors can result in costly investigations

Would you rather pay for an audit or pay for an investigation?

Finding the time to keep your providers up to speed on coding and billing regulations may be a challenge, but it’s arguably better to make the time on your terms rather than have it imposed during a potential investigation. It’s no secret that the government is looking into potential fraud cases more now than ever, and if your provider is investigated do you have the confidence and peace of mind that your healthcare organization is in the clear?

The Bottom Line

Audits for regulatory compliance and process improvement should be completed on a consistent basis to identify education opportunities. Your providers, coders, and billing office could be innocently making mistakes that potentially result in a serious expense to your organization. Making time for provider audits is a necessity as the healthcare laws change and it becomes more challenging to stay on top of it all.


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