How to Prepare Your Clinics for a Potential Audit

A2C How to Prepare Your Clinics for a Potential Audit

You’ve been helping your patients and doing everything right. However, even when things are done right, it’s a good idea to be prepared for a potential audit. Not only do you have to prepare one location, but multiple clinics that must be prepared for potential audits. There are several major red flags that are more likely to trigger an audit and the majority are related to documentation. No fear — Clinic Controller: Therapy can help you avoid, or at least mitigate, these problem areas based on the type of audit.

Types of Audits

Recovery Audit Contractor Audits

This type of audit was created under the Medicare Modernization Act of 2003 and conducts retrospective fee-for-service claim reviews. This particular process is a “claw back” and is used to reclaim money. The country is divided into four regions and payment is received based on these regions. Initially, these types of audits were primarily focused on upcoding and site of care but have transitioned to medical necessity. Part of this can be mitigated through care plan development and certification. In fact, this should be your first step for all patients entering the clinic. Without this certification, you don’t get paid by Medicare. You’ve got 30 days to get this information from each patient and it’s used to prove that patient care is overseen by a physician. The elements include:

  • Date of effectiveness
  • Patient diagnosis
  • Treatment goals
  • Therapy services specifics—such as type, duration and frequency
  • Date, professional identity and signature of the individual establishing the plan
  • Date and signature of the overseeing individual (typically a physician) showing if the plan is agreed upon or if changes are needed

It’s also important to be sure that no point of care certifications are missing, all are up-to-date and that re-certifications are completed at the appropriate time.

Comprehensive Error Rate Testing Audit

This type of audit is conducted on an annual basis and is, “based on a statistically valid stratified random sample of Medicare FFS claims to determine if they were paid properly under Medicare coverage, coding, and payment rules.” Your clinic can protect itself in these types of audits in different ways. First, to service patients with Medicare, your clinic has to be certified to do so. First things first—be sure you’re Medicare certified. Then, be sure you engaged in appropriate and well-documented billing practices. Avoid these errors that may lead to an audit:

  • Inaccurate billing for technicians or aides
  • Not billing group therapy when the patient uses group therapy and, instead, billing independent (one-on-one) therapy
  • Co-treatment billing in cases where none occurred
  • Billing 
    • Medicare for treatment without documented medical necessity
    • Based on unbundling or upcoding services
    • Based on medical necessity when none exists
    • For an unusual duration or frequency for the services needed
    • For services that were not given
    • For student-provided services

Probe Audits

Probe audits are for certain services or specialties and you must meet particular criteria. If your clinic meets these criteria, a sample of submitted claims will be reviewed prior to payment. You will also likely have to submit more documentation by a certain deadline. The next part is simple enough: If you don’t do it, you don’t get paid. On the other hand, if you do comply but not enough support for the billing is in the documentation, you won’t get paid for those claims. Finally, if you’re found to engage in fraud, you will be further investigated.

As you can imagine from the types of audits, documentation is critical to preparing for an audit. However, in all cases, be sure your documentation is signed by the appropriate party, is legible and is not reproduced using a stamp. Clinic Controller: Therapy can help with the preparation of your documentation.

Documentation

In relation to Clinic Controller: Therapy, documentation is the most important thing you can do to prepare for potential audits. We will act as your trusted partner and are ready and willing to help you bring activity back into the lives of your patients. We are committed to helping and supporting you until the most challenging job is done.

Clinic Controller: Therapy was designed by therapists for therapists. This means you can take advantage of our comprehensive reporting system that can review the operations of your clinic from multiple angles. You can get the most appropriate data summary to make the best decisions through our flexible and customized reports. Here’s how Clinic Controller: Therapy can help:

Executive Reports

Our service gives you executive reports— which are designed to summarize different areas in one report. As a result, you will get a panoramic view of the clinic and all its operations. With the executive report, you’ll get information regarding therapist productivity (including patients seen, cancellation rates, no-show rates, therapist loading, patient charges and patient collections) and clinic productivity. You’ll also get information regarding the overall billing and collections, the business cycle and historical aging of the clinic. In relation to patients, the executive report will tell you who referred them.

Standard Reports

Clinic Controller: Therapy gives you standard reports, which help you answer specific questions or engage in task expedition and support. Standard reports are highly interactive and make it so you can navigate throughout areas of the application as you need. Standard reports provide information regarding all checked-in but not-yet-charged visits. More importantly, especially in relation to potential audits, standard reports provide information regarding insurance status, allowing you to view all carriers and cases based on an aging bin for insurance claims.

Base Reports

Clinic Controller: Therapy offers base reports, which gives you data-mining capabilities and the basis for new reports. These reports feature basic spreadsheet functions, so you can manipulate the data found in columns. You can also group or filter rows based on certain criteria and share the results with other users.Each of these report styles are beneficial for helping you prepare for potential audits because—as stated—the most important part of preparing for an audit is documentation. For help in preparing your documentation for a potential audit by using Clinic Controller: Therapy, contact us today!

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