10 tips to surviving an insurance audit


To protect you and your practice, it is important to have a plan and process in place in the case of an audit

The views expressed here belong to the author. They do not necessarily represent the views of Optometry Times or UBM Medica.

Many medical plans (Medicare, Tricare, etc.) as well as managed vision plans (VSP Vison Care, EyeMed Vision Care, Davis Vision, etc.) have an ongoing process to audit payments to providers.

The audits can be random or can be targeted to your practice due to billing patterns that fall outside the norm. Insurance companies use big data analytics to compare what and how you bill your services.

Previously from Dr. Spear: 5 steps to creating a budget

If you are an outlier, chances are you will be the target of an audit.

To protect you and your practice, it is important to have a plan and process in place in the case of an audit.

Our practices have been audited numerous times and having a plan in place helped us get through it.

Here are ten tips to help you survive an insurance audit at your practice.

Click here for 10 tips to surviving an insurance audit




1.Know the rules

Have you read your vision plan contract? I ask that question on a regular basis when I am lecturing on the topic of billing and coding.

For many offices, managed vision plans make up 70, 80, or even 90 percent of the patient base and revenue.

What is the percentage in your office?

How can you run a practice with the majority of your revenue coming from a source for which you have not read the contract?

Related: Does your practice have a culture of can’t?

Incredibly, my experience has been that less than five percent of ODs have read the manual and contract they signed with their respective vision plans.

It has also been my experience that more than five percent of ODs complain about managed vision plans.

How can you complain if you don’t even know the rules?



2. Don’t assume a records request is routine

Some record requests and audits are routine. Others are not routine at all. This is why it is important to provide the insurer with the correct information within a timely manner.

There might be some hints in the insurer’s record request.

For example, if every record requested by an insurer involves a patient with diabetes and a specific code-that’s a strong indication that the request is a targeted search on that code.

In contrast, if the request covers a seemingly random number and type of patient-it’s probably a routine audit.

Related: 6 steps to open a practice

You won’t know for sure if it’s a targeted or routine audit, so it’s always important to be mindful of what you’re sending.

Never assume any audit is routine.

Any time that your medical records are out for review, you are exposing yourself to the insurer’s scrutiny-along with the penalties and liabilities that come with noncompliance.

Did I mention you should read the rules?


3. Be involved

Make sure that your billing staff isn’t handling the audit requests automatically without your knowledge. It’s critically important that you are involved in looking at the audit requests themselves and then reviewing what records are sent to the insurer.

I said reviewing-not changing!

Related: 5 zones of your practice that need TLC

Never change records or make corrections. However, as we will discuss later if you see that the records requested are not clear, it is acceptable to do addendums and letters to the auditor explaining the documents submitted.

Ultimately, you are responsible for the records. No matter how good your billing staff may be, they are not as vested in the process as you are-or you should be.


4. Follow instructions

Some managed vision plans, like EyeMed, make it very easy. You can log into your EyeMed account and print out the company’s scorecard-which details exactly what the auditor will want to see.

If that level of detail isn’t available from the auditing insurer, contact it and make the request for what is required.

Related: How to prevent no-shows in your practice

If things do go bad during the audit, having made the request for what is required can be very important.

It is unfair to be held to an unpublished requirement. At a minimum, refer to your manual for that provider and see what is required specifically for the codes covered in the audit request.


5. Review package before mailing

Even if you were involved in selecting which pages to print or copy, make sure that you review the final package being sent to the auditing insurer.

The records are often requested in a specific order. During the process of compiling documents, pages might fall out of order. Double-check the package before sealing the envelope and sending off.

Related: 3 steps to staff empowerment

Put together a cover letter to send with the package. Make sure that your cover letter and package include the exact information requested by the auditing insurer.

Remember-details matter!

6. Ask for a second set of eyes

If you don’t have a partner or business associate, consider asking an OD friend or hiring a consultant to help with the process.

My wife Katie has helped a number of doctors with record reviews, and recently she was working with an OD on an audit.

During their conversations, the OD had told Katie about one portion of her exams that she was unable to track. When the OD reviewed the requested records, there was no documentation whatsoever of that particular portion of the exam being done.

Related: Be present with your patients

Katie was able to track it back to the electronic medical records (EMR) and noticed that the filter box to print that particular task was turned off. So a key component wasn’t printed because of a setting in the EMR.

Luckily, this was caught before the files were mailed to the auditing insurer.

Little things like this can prevent a ton of problems on the back end.



7. Assist the auditor

If you discover any irregularities as you’re preparing your records, address them in your cover letter.

Auditors review an awful lot of records. If your cover letter explanation makes sense, you can spare the auditor from having to call you and delaying the audit process.

Related: How to combat stress in your life

It’s a better strategy than hoping that the irregularities go unnoticed.

In some cases, it may be necessary to do a “summary of care letter” an explanation on each record requested.

The key is to do as much work as it takes on the front end in order to give the auditing insurer a clear picture of what you did and what your thought process was for each record.

8. Be timely

Most audits allow a few weeks to gather the records. Don’t wait until the last minute to compile them.

Be mindful of the deadlines. For this reason, start right away.

Related: Does your practice have a hive mentality?

Compile the information and start following the rest of the tips provided. If it is a very complex audit, you can request and extension and clarification on what the auditing insurer is requesting.

Communication with the auditing insurer is critical. Don’t think it will go away or take care of itself-be proactive.


9. Learn and adjust

No one enjoys being audited, but audits also provide you and your staff a chance to make sure that documentation and billing is correct and complete.

It is critically important for everyone to learn from the process.

Related: Looking back at 2016

Use the feedback and results of the audits to train everyone on what can be improved. It is important to incorporate the results of the audit into your ongoing quality assurance and compliance plans.

Yes, you need both.



10. Marry wisely

Now, in full transparency, I hate talking about audits.

I hate the level of detail required to be good at preparing for them. My stomach turns at the thought of going through records to get them ready for an audit.

You see, I am a big-picture strategy guy-details are not my thing.

Related: How a blue ocean strategy can keep you competitive

So my last piece of advice is to marry wisely.

Katie, my wife, loves this stuff. Digging into the audit request and finding all the little details and clues is right up her alley.

So, marry wisely and happy audits.

Thanks for all the emails and questions. I appreciate hearing from all of you. You can reach me at chspear@gmail.com

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