Toolkit Helps Physicians Facing Medical Audits

The Physicians Advocacy Institute (PAI) and the American College of Emergency Physicians (ACEP) have created a resource aimed at providing practical tools for physicians facing medical audits.

PAI and ACEP developed the toolkit to help physicians struggling to respond to the increased use of medical audits by federal, state, and private health care payers. It provides physicians with practical resources and information to help assess if their practice is a likely candidate for an audit and tools to help respond to an audit request and, where necessary, assist in appealing audit findings.

Medical audits are disruptive to physician practices and often cause substantial financial hardship as many payers delay or cease payments to the audited practice until audits are complete or recoup alleged overpayments before any ruling on appeal. However, physicians need to consider medical audits as a routine part of their businesses and plan accordingly. There are many actions that physicians can take to mitigate both the risk of being audited and the potential for adverse audit findings in the event of an audit, some of them quite simple. For example, physicians can assess the risk of an audit before it occurs by using information available on the Centers for Medicare and Medicaid Services’ website to determine if their billing is out-of-line with others in their specialty. Physicians can also assess their risk of an audit by reviewing Medicare’s Comprehensive Error Rate Testing (CERT) report to determine if they bill codes that are “frequently improperly paid” by Medicare.

Physicians can mitigate the potential for adverse audit findings by ensuring that their electronic health records systems are not set at default levels and that they input information regarding a patient’s history and diagnosis codes related to the conditions addressed on the date of service. Physicians can also mitigate the potential for adverse audit findings by ensuring that a complete copy of a requested patient’s medical record is provided to the auditor. Careful attention must be paid when submitting medical records to facilitate the audit process and help prevent adverse results.

Audit findings are often erroneous. For example, an August 2013 Department of Health and Human Services Office of the Inspector General report found that approximately 44 percent of all appealed RAC contractors’ findings of alleged overpayments are overturned at the third level of appeal. Therefore, physicians also need to be prepared to appeal when they believe a demand for repayment is based on erroneous findings. The Toolkit contains information to assist in analyzing whether an overpayment demand is erroneous and tips for filing appeals.

The Toolkit contains several practical resources including: Medical Audits: Top Ten Tips for Physicians to Anticipate, Respond, and Protect Their Practices, Physician Checklists for Submission of Medical Records in Response to an Audit Request and for Appealing Audit Findings, and articles with detailed information about medical audits.

In addition, PAI and ACEP intend to offer a series of webinars based on the toolkit.