Scoring & Reporting Your Audit Findings

February 2nd, 2018 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
Categories:   Audits/Auditing   Evaluation & Management (E/M)   Compliance  
0 Votes - Sign in to vote or comment.

This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.

I have a question regarding external audit results. We have recently contracted with a new auditing service to provide external audits for our providers. They do a great job, but the way they score E&M charts is different from our internal policy. If they find that an E&M level is off, no matter how many levels, they count it completely wrong, whereas internally we weight the score so that if it is one level off they get a 90% for that chart, two levels is a 70% and so on.

A question though - would changing the audit score be considered fraud?

There are no "rules" specific to the scoring process of an audit. Well, actually there are not many rules about the compliance auditing. Below this article, you have been provided a link to the Federal Register, specifically the Developing the Compliance Program Guidance for Individual and Small Group Physician Practices. While this is a monotonous 19 page document, it does hold within it the guidance we have regarding the OIG's expectations for compliance and auditing practices associated with an effective program. Interestingly enough, there is no guidance in the Federal Register that pertains to creating audit reports, nor does it refer to reporting the Precision Rating of the provider.

Your Reports: The way your organization chooses to create feedback from a compliance audit is completely at your discretion. Your organization should have guidance within your Auditing Policy, as part of your Compliance Plan that would identify expectations of your standard auditing report. Whether you all choose to include a Precision Rating or not, the report is merely a tool by which to educate the provider and maintain as due diligence of your invested efforts towards compliance.

When our organization provides audit services we would do the same as the company you are using. Why? Because when the OIG states a provider should have a 95% accuracy rating, they mean right or wrong, not by one level or two.

That being said, we provide audits for many organizations that do similar internal scoring mechanisms as you have, and again I am not saying yours is wrong by any means-nor am I saying theirs is wrong. You could approach this one of 2 ways: 

  1. Ask the firm to use your scoring policy. Many will honor such requests, and any pushback you may experience from this is NOT due to compliance concerns, but rather it will increase their workload. This takes their team out of their "norms" and requires additional QA to ensure that everything is accurate according to your plan.
  2. Ask the firm to NOT score the audit, to merely provide you with the findings and then use your internal scoring mechanism. Once you receive their reports, while it would cause a bit more work for your team, you could then score them your way prior to distribution.

In 2017, we created a questionnaire to provide rationale to our scoring process for potential clients. We have found that this helps create a project that meets client expectations, while ensuring duplicative efforts are not required to "re-score" our audits. Moving forward, ask ahead for their scoring and reporting practices prior to initiation of the project.



Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.

Latest articles:  (any category)

​​Polysomnography Services Under OIG Scrutiny
September 2nd, 2021 - Raquel Shumway
The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
August 16th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
Billing Dental Implants under Medical Coverage
August 12th, 2021 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...
New Codes for COVID Booster Vaccine & Monoclonal Antibody Products
August 10th, 2021 - Wyn Staheli, Director of Research
New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.
Medicare's ABN Booklet Revised
July 29th, 2021 - Wyn Staheli, Director of Research
The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.
Chronic Pain Coding Today & in the Future
July 19th, 2021 - Wyn Staheli, Director of Research
Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
July 15th, 2021 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...

Home About Contact Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2021 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association