6 Factors that Can Lead to Health Insurance Audits and How to Avoid Them

Pristine documentation is the best defense when it comes to health insurance audits. 

The goal of a health insurance audit is to prevent healthcare providers from exploiting the system by overcharging patients. While insurance carriers and the government routinely conduct audits as mandated through the Fraud and Abuse program, some factors can actually trigger a health insurance audit. Let’s look at some of the factors that could trigger an audit of your medical records and what you can do to prevent that from happening.

1. Inadequate Documentation

One of the most important factors when it comes to health insurance audits is documentation. If you don’t have adequate and proper documentation, you may not get paid for the service. Documentation helps prove that you actually provided the services you’ve claimed and that the services you provided were at the level to which they were billed. It also shows that those services were medically necessary. 

You can use SOAP notes to keep accurate, concise, and precise records regarding every patient encounter. Try to document everything, including simple things like signatures, and ensure your documentation is patient-specific. Insurance carriers usually look for information regarding: 

  • Thorough assessment  
  • Diagnosis justification issues addressed 
  • Identified treatment plan 
  • Qualified services, i.e., are you qualified to treat? 
  • Progress update 

Make your documentation time efficient with A2C’s 80+ built-in templates and quick phrases. Pick and choose what goes into your notes and evals using only the info and metrics you want, getting documentation done in minutes, not hours. 

When using our flow sheet, there is no way to charge for a service that wasn’t documented. In fact, we have had several customers who have passed audits with flying colors all due to their detailed flow sheet notes.  A2C Medical’s flow sheet forces compliance with:  

  • Objective text that is automatically populated based on the functions (treatments) that are performed  
  • Calculated units based on direct contact time   
  • Charges only applied after the note is signed by the therapist   
  • Changes only made to items they have marked off in the flow sheet 

2. Patient Complaints

Insurance carriers often provide hotline numbers where patients can call if they have any issues with their bills. These issues can range from billing for services they didn’t receive to unfair treatment. To avoid getting audited due to patient complaints, you must provide the first outlet for your patients to obtain information or ask questions. Encourage them to reach out in case of any problem and respond promptly to their inquiries. You can often defuse the situation by providing a satisfactory answer or solution to their question or concern.  

3. Coding Issues

Coding issues in your claims processing can trigger a health insurance audit. Instances of upcoding and undercoding are common problems for therapy clinics. Upcoding occurs when you use coding for a more expensive procedure or service than was actually performed. For example, coding for a full exam lasting 45 minutes when you only met a patient for a few minutes is upcoding. Under-coding, on the other hand, is the opposite of upcoding. It refers to coding for fewer services than you actually provided or leaving out codes from a patient’s record.  

While upcoding can be accidental, a pattern of such improper representation of rendered services can lead to legal consequences and fines from both private and government payors. Some practices use under-coding to save patients some costs; this fraudulent billing has legal consequences and could flag you for an audit.  

Unbundling is another coding issue providers face. Unbundling is when a coder bills for multiple CTP codes for all portions of a procedure when a single, more suitable code would suffice. Coders often use unbundling as a means to increase payments, or it can be a simple misunderstanding of billing practices. Either way, this is a red flag that can trigger an audit. Be careful not to approximate a code, and if there’s a combined code to capture all components of a service, use it instead of using several codes. To err on the side of caution, always follow unbundling rules and stay up to date on the latest CPT codes used by your specialty. 

Excessive use of specific ICD-10 codes and certain CPT codes can also trigger audits. Entering the wrong code, entering too few or too many digits, or getting codes confused can also be disastrous. To avoid any legal issues and health insurance audits, update your principal medical sets annually and ensure your coding is accurate and compliant at all times.  

With Revenue Cycle Management services from A2C, you can have a fully-integrated resource to help identify coding errors and submit cleaner insurance claims.  

Check out another article that can help you master coding for your clinic: Physical Therapy Insurance and CPT Codes – What Providers Need to Know 

A physical therapist working with a client and documenting properly to avoid a health insurance audit.
Cautious coding can save you from having to deal with the massive headache of a health insurance audit. 

4. Billing Errors

Billing errors are huge audit triggers. You may have billing errors such as unbilled lab services, patient visits provided but not charged for, repeated rejection of some services or minor procedures documented but not reflected on the superbill. 

Other common billing mistakes include confusing two different claims, entering incorrect patient or provider information, or failing to verify the patient’s insurance before the procedure took place. While billing mistakes are challenging to eliminate, it’s possible to reduce them. A robust billing service with revenue cycle management can help you avoid inaccuracies and billing errors resulting in an audit. 

5. Computer Monitored Practice Patterns 

In this age of technology, payers often monitor your practice patterns using data mining and statistics. Above-average use of procedures and outlier payments and high denial rates can lead to an audit.  

Payors may analyze comparable practices in one geographical area to determine utilization rates. Or perhaps your clinic starts billing a new procedure. This doesn’t mean all outlier patterns are fraudulent or non-compliant. You may have a reasonable explanation, such as the use of new equipment causing increased billing for its use.   

You can avoid an audit by understanding and keeping track of your data. Ask your coding and billing departments to run a report comparing you to other providers of your specialty to determine if you’re an outlier. Or use your practice management system to review your practice patterns. 

6. Random Selection

At any time, a payor can decide to audit your practice. You can be selected for a random health insurance audit through a mix of audit triggers or for no determinable reason at all. While most random audits have few material findings or none at all, they help identify any improper billing patterns that would have gone unnoticed under current selection parameters. This is why it’s always important to be keeping tabs on some of the items that can hurt your practice in the case of an audit.  

Maintain Compliance with A2C Medical

Most of these audit triggers are related to billing and coding. It takes a seamless, highly efficient system to conduct medical claims processing without critical errors. At A2C Medical, our EMR software provides a seamless claim generation experience, ensuring no data is incorrect or missing. Our dedicated billing specialists will identify and track every stage of your revenue cycle within the EMR software, fix any errors, and ensure that the claims are correct. To learn more on how the A2C EMR software can help you stay compliant and avoid a health insurance audit, contact us today to schedule a demo. 


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