How to Prepare for a Healthcare Audit: Best Record-Keeping Practices

Prepare for a Medical Practice AuditIt doesn’t matter what type of business you run, nobody wants to be the subject of an audit. When it comes to a healthcare audit, it can be even more stressful. Changes to the healthcare industry have put a real strain on medical practices. Comprehensive record-keeping and staying on top of medical billing services are more important now than ever before. Conducting your own temperature-taking methods in-house, such as performing an annual fee schedule review, offside CPA audits and working with healthcare consultants to ensure that you are current with all of the latest requirements, will make facing a healthcare audit a lot less stressful.

Stay Ahead of the Game
The best way to handle an audit is to prepare for it in advance. You can do this by reviewing your comprehensive record-keeping techniques on a regular basis, either on your own or through the use of a reputable third-party, such as MD Pro Solutions. Knowing what the auditors are looking for can be helpful as well. Not only will this help you when it comes time for a healthcare audit, but it will help you to provide the best possible care and service to your patients. Many advantages come from having a smooth-running office and billing department, including increased patient happiness, better local ratings, more referrals from other area physicians, and much more.

Specialists have even more reason to pay attention to their reputations. Even more than family doctors or general practitioners, specialists like doctors who work in Ear, Nose & Throat (ENT), are more likely to get “checked out” by patients ahead of time. You want to have a solid reputation in all of the medical review websites and pages from both patients and other doctors who have referred their patients to you. Staying on top of medical billing services and performing an annual fee schedule review in addition to using offside CPA audits, can provide you with “temperature taking tools” that will help you know how well your practice or clinic is performing, and what areas need work.

What Does an Audit Look For?
When you are the focus of a healthcare audit, there are a few things that the auditor will look for specifically when they come to your office. The primary thing is to look for medical records that are not properly or sufficiently documented. This is why setting a standard in your office for comprehensive record-keeping is so important. It must be done properly every single day for every single patient that you see. In addition to looking at your medical billing services and making sure that you are working within current healthcare regulations, auditors also look at the following areas of your record-keeping documentation:

  • over-coding and under-coding
  • unbundling issues
  • misuse of modifiers
  • basic documentation – patient ID, signatures, etc.
  • special tests – order in the records, interpretation, report and proper billing codes
  • medical necessity and Advanced Beneficiary Notification issues
  • initiation of diagnostic and treatment program
  • comprehensive record-keeping from initial visit to diagnosis and treatment

What You Need to Know
Working with a healthcare consultant can help you prepare for future healthcare audits, including an annual fee schedule review, offside CPA audits and general healthcare audits for otolaryngology practices and clinics. It is important that you know that you are not required to give over the original medical records, but you are allowed to make copies. You should keep an accurate accounting of every single medical record that was requested and provided to the auditor. You should never make corrections on a medical record after it has been requested. Your best bet is to add an addendum to the file if you note any discrepancies.

If you do your own in-house reviews, make sure to check for specific areas within the patient records to ensure proper documentation and comprehensive record-keeping. Go over your current medical billing services and take a look at how your office staff handles their billing, coding and record-keeping duties on a daily basis. If you don’t have time to make these observations on your own, as many practices are overwhelmed with patients at certain times of the year, contact a healthcare consultant, such as MD Pro Solutions, and get a second opinion. Dotting all of your i’s and crossing all of your t’s, you should be looking for basic mistakes, such as signatures on the records, exam notes for each visit that gets billed, ensuring that the notes support the patient’s diagnosis, documenting referrals, and making sure that orders are written for any special tests.

Give us a call at 508-946-1665 to learn more about all of the services that we provide at MD Pro Solutions that can help you to make improvements to medical billing services and comprehensive record-keeping that will prepare your practice for a healthcare audit. From annual fee schedule reviews to office CPA audits, medical billing training and support, outsourced billing services, account management education and much more, MD Pro Solutions specializes in providing services for otolaryngology practices and clinics.