Surviving Common and Costly Audits

by Robert Rebello, President, EyeCor Nteon
reprinted by permission


All of the insurance companies have significantly increased their audits. One of the major reasons is the average penalty for a negative insurance audit is between $100,000 and $200,000! When you do the math, with only ten audits, they make $1,500,000! With the number of practices the insurance companies audit, this results in more money than can be obtained in fee cuts!


To ensure an increase in their audits, the companies have increased the number of auditors. Some audits are random and others are a result of information provided by the practice through a request for records. Some insurance companies schedule audits in advance. Others conduct surprise audits.


Nteon Practice Consultants, performs "pre-audits" for practices across the country. A "pre-audits" will assist in ensuring your practice would survive an insurance audit, thus avoiding a severe financial penalty. Consistently, most practice owners say they are sure their exam documentation is compliant and want our pre-audit just for "peace of mind." Occasionally, practices admit their documentation is non-compliant. Unfortunately, we find most practices are non-compliant! If audited by any of the insurance companies they would have been assessed significant penalties.

 

Reasons for Negative Audit Findings

As a result of our pre-audits and helping practices that have been hit with an insurance audit, we see the most common reasons for a negative insurance audit.

 

For paper exams the most common reason is poor handwriting. Most doctors who have paper records do not fully comprehend if the auditor cannot read the documentation you will fail an audit. The auditors will not take your word for what your records have.

Another important observation is that (except for poor handwriting) there are more compliance issues with EHR systems than with paper records. There are two primary reasons.

One major and common problem is that a printed report does not contain all the information the doctor has recorded in the EHR system. Insurance auditors rely on print outs of exam documentation. When the auditors review printouts that are missing exam documentation, depending on the amount of missing information, this will result in severe negative findings only because the EHR did not print the report correctly! Even if you get this reversed, it will cost you time and money for the appeal process.

Make sure your printouts contain all of the information in your exam record. If not contact your EHR vendor immediately to have it corrected. Do not wait until you receive a request for records or when an auditor shows up at your office!

 

Another problem is the usage of non-compliant templates. In most, but not all, cases the templates supplied by the EHR vendor has most of the required information to pass an audit. One problem that arises is when the practice changes the templates to make it look more like their paper charts. Unfortunately, as a consequence of these template changes, required
information is frequently eliminated. This results in noncompliant exam documentation and failed audits! We also find cases where the default templates supplied by the EHR vendors are not compliant.

 

By far the most common problem for Medical Exam documentation is missing or incomplete patient history, Review of Systems and History of Present Illness (Chief Complaint). There are specific minimum requirements for each of these. Most EHR systems do not verify the minimum amount has been entered. This results in finalizing of non-compliant exam documentation!

 

Top 10 Reasons for Negative Audit Penalties

  1. Missing or incomplete HPI / Chief Complaint
  2. Cloned Records – EMR Systems
  3. Missing or incomplete Interpretation and Reports
  4. Paper Records – Illegible records
  5. No documentation “Initiation of Diagnosis Treatment”
  6. Insufficient Patient History (PSFH)
  7. Insufficient Review of Systems (ROS)
  8. Insufficient Exam Elements
  9. Diagnosis Inappropriate or not Supporting Exam Level
  10. Medical Decision Making not supporting Exam Level

 

Take Audits Very Seriously We still hear from doctors where they do not believe audits are as common and serious as they are. A doctor that had been in one of my lectures and thought I was exaggerating. Later he was audited and hit with a fine of over $100,000! He said he wished he believed me.

 

Please take this seriously. I have heard from too many doctors trying to figure out how to survive a negative audit where they have been hit with high penalties.

 

For more information on how to avoid a negative insurance audit, contact Nteon Practice Consultants.

Make sure your printouts contain all of the information in your exam record. If not contact your EHR vendor immediately to have it corrected. Do not wait until you receive a request for records or when an auditor shows up at your office!

 

Another problem is the usage of non-compliant templates. In most, but not all, cases the templates supplied by the EHR vendor has most of the required information to pass an audit. One problem that arises is when the practice changes the templates to make it look more like their paper charts. Unfortunately, as a consequence of these template changes, required
information is frequently eliminated. This results in noncompliant exam documentation and failed audits! We also find cases where the default templates supplied by the EHR vendors are not compliant.

 

By far the most common problem for Medical Exam documentation is missing or incomplete patient history, Review of Systems and History of Present Illness (Chief Complaint). There are specific minimum requirements for each of these. Most EHR systems do not verify the minimum amount has been entered. This results in finalizing of non-compliant exam documentation!

Are vision plans killing your practice?

In everyday practice most all of us have encounters with patients with benefits from Vision Care Plans (VCP). Here is an opportunity for you as an individual optometrist to communicate with the Vision Care Plans your individual views, both pros and cons, in a professional manner, in order to maintain highly effective patient care.

An Invitation to Join THE Optometric Society

Friends and Colleagues,

I would like to take this opportunity to personally invite all of you to join the The Optometric  Society [TOS], which will give individual optometrists an increasingly important voice in our profession.  I ask all optometrists to join to insure that our voices be heard.

THE Optometric Society was formed to ensure that individual optometrists continue to thrive, independent of the influences of industry and "big medicine."  In part, THE Optometric Society will help foster a healthy debate on the issues facing optometry today.

THE Optometric Society is a professional membership organization, comprised solely of optometrists. Concern over the present state of the profession should prompt Optometrists in all modes of practice to join.  Dues are $150 per year and you may register here as a Founding Member till the end of 2014.

If you wish additional information, you may contact THE Optometric Society administrator (This email address is being protected from spambots. You need JavaScript enabled to view it.) or (909) 742-9311.

Unlike the AOA, our elected Board of Directors will serve and be directed by the views and wishes of the membership.  You will be an active and integral part of THE Optometric Society, as the organization works to address the needs of the members with the passion and commitment you expect of your professional society.  I look forward to welcoming you to our society.

These are Your Elected TOS Board Members, feel free to contact them through the website: www.theoptometricsociety.org

  • Gary S. Litman, O.D., F.A.A.O., Vice President
  • Michael A. Santarlas O.D., Treasurer
  • Lisa Shin, O.D., President
  • James Sanderson O.D., Secretary

Professionally yours,
Dave Carlton OD   [National Membership Chair]

P.S. Be sure to mark your calendar for the 2015 Annual CE Symposium April 24 – 26, 2015 in Dallas.  More information can be found at www.OptometricCE.org.  Registration opens November 1,2014.

Free Membership Offer

FREE MEMBERSHIP IN THE OPTOMETRIC SOCIETY

THE Optometric Society has partnered with Total Merchant Services to offer credit card processing for your office.  TMS offers exceptional value for those members who choose to use their services.  TMS offers the following benefits:

  • Free state-of-the-art equipment.
  • Preferred Partnership Pricing - 10% savings guaranteed off your current provider.
  • Turn-key installation and Staff Training.
  • Pin Debit Capability to insure the lowest transaction fees.
  • No long term contract.
  • $300 sign up bonus
  • $150 reimbursement for your membership dues!


Visit the member benefits page for more details about TMS services.