Prospective audits

March 29th, 2009 - Codapedia Editor
Categories:   Coding   Compliance  
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Many physician practices took the OIG recommendation to heart, and do annual compliance audits.  There are many questions to answer about audits:  how many, how often, internal or external auditor, doing the work under attorney client privilege and whether to do the audits prospectively or retrospectively.

Prospective audits are done before the claim is submitted to the payer.  The auditor reviews the record, selects the correct CPT®, ICD-9 codes and modifiers, and determines if the claim meets other government regulations.  The practice then submits the claim with codes selected by the auditor.  There is no claim to correct, because the claim isn't submitted until after the medical record is reviewed.  That is one of the main advantages to prospective audits.

The disadvantage is that the practice has to hold the claim until after the audit is done.  If a copay or coinsurance amount was collected, the practice must have a system in place to post that payment, before the charge is posted.  The charges aren't submitted, and if the audit is large, that delays payment to the practice.  The audit needs to be scheduled carefully with the auditor, and the notes submitted to the auditor according to a schedule. 

Because prospective audits do not require any claim re-submission, some practices do not use an attorney when doing prospective audits.  But, keep in mind that any audits done without attorney-client privilege can be obtained by CMS.

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