Industry Trend: Probe Audits and Data Mining

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Industry Trend: Probe Audits and Data Mining

Wednesday, September 23, 2015

By: Laura Lovett, CPC, CPMA, CPC-I, CANPC, CEMC, Data Integrity and Compliance Consultant, The Rybar Group, Inc.

Nobody wants to be audited. Nobody has time to be audited. Unfortunately that is the reality healthcare providers face; external audits can be initiated at any time.

Currently, we are seeing providers from various specialties and in multiple states, receiving probe audit letters from their respective MAC. The letters are identifying these providers as being high utilizers of a particular E/M code when compared to their peers. Being a high utilizer does not automatically mean there is a problem. The services could be medically necessary, appropriately documented, and coded correctly. If they are not correct, what was just a probe audit can turn into a much larger audit and the MAC will require the provider to refund the over payments.

So what should providers do? Either implementing or continuing to maintain an effective compliance plan which includes auditing and monitoring is the first step. The goal is not to change your coding and billing practices to fit in to a particular pattern. The goal is to provide medically necessary services to the patients, document those services appropriately, and receive correct reimbursement for the services rendered. If that happens to send up a flag when data mining occurs, so be it.

Nobody wants to be audited. Nobody has time to be audited. Being audited should not create fear and anxiety. Being audited should just be business as usual and a minor inconvenience. Make sure any audits you face are just that by keeping tabs on your documentation and coding through internal auditing and monitoring.

Laura Lovett is a Data Integrity & Compliance Consultant for The Rybar Group, specializing in the area of Professional Service Coding, Auditing and Education. She can be reached at 810.853.6173 or via email at LLovett@therybargroup.com.