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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 using loopholes to make huge profits on markups for these chairs.

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

1. Billing mistakes are still the provider's problem

You may have read the headline about the $250,000 typo that was narrowly avoided by a NY cancer center. Billing mistakes can and will happen. 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 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 can catch mistakes and provide the opportunity to correct them. 

3. Technology may add to the compliance confusion

Your patients have unique concerns and needs. While technology is great, it may be limited on the level of customization you need.   For example, there is a cloning feature in most EMRs so the provider can copy the same note to use for multiple patients with similar conditions. 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. The provider should take the time to update the documentation to reflect each visit. Completing an external audit where an outside party reviews the documentation to ensure all guidelines are followed could be a worthwhile investment for your organization.

4. Unintentional errors can result in costly investigations

Would you rather pay for an audit or 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.  Investigations can hurt your reputation and diminish trust among your patients and stakeholders. 

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 making innocent mistakes and putting your organization at risk for serious fines.  Make time for provider audits as you work through the ever-changing healthcare law landscape. 


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