• Electronic Medical Records (EMR)
• Scheduler with Eligibility Test
• Compliance Management
  + Core Elements
  + Regulatory Risks
  + Auditing and Monitoring
  + Documentation Guidelines
  + Audit Exposure Evaluation
• Data Entry and Payment Posting
+ Charge Entry
• Superbill Interface
• Variety of Claim Entry Formats
• Fax
+ Demographic Data Entry

• Coding
  + Coding Consistency
  + Discovery of Undercoding
• Claim Submission to Payers
• Patient Invoicing
• Follow Up
  
+ Discovery of Underpayment

• Transparency, Analysis and Reporting
• Quality Control
  + Billing Process
  • Payment Distributions
  • Days in A/R
  + Claim Validation
  + Patient Eligibility Testing
  
• Data Center
  

Audits are most commonly use to review the accuracy and completeness of documentation, coding, and billing records to

1. Protect the practice against the submission of claims that could be construed as false and fraudulent,
2. To identify overpayments received from payers or patients that should be refunded, and
3. To identify under coded claims for fear of insufficient documentation and payer audit.

Such audits typically take two forms:

1. Standards and procedure review
2. Claims submission process review

Audits improperly conceived or conducting can be very damaging to the practice. The OIG sets a basic review guideline of five to ten randomly selected records per federal payer or per physician. These records then must be tested for specific coding and billing regulatory risks. The OIG also prefers that the audits use the same sampling protocol “RATSTATS” (www.hhs.gov/progrog/oas/ratstat.html) The benefit of using this protocol is added credibility to audit results and reduced likelihood of questioning by OIG.

Alternatively, you may draw 5-10 samples of claims per payer per physician from the universe that you consider high risk in comparison to “E and M” coding. OIG recommends a typical audit to be performed on an annual basis or upon identifying at least of the following warning signs:

1. Significant change in the number/type of claim rejections
2. Payers challenging the medical necessity or validity of claims
3. High volumes of unusual charge or payment adjustments

_________________________

* Much of the material for this section of the website follows “Understanding Compliance: A Program Guide Based on the OIG 2000 Guidance,” by R. Saner, M. Spindel, A. Nordeng, Powers, Pyles, Sutter & Verville, P.C., MGMA, 2000