Practice Managers and Auditors: Learn to Stand Your Ground with Payers

Posted by Nancy Clements on Apr 13, 2021 5:15:06 PM

Changes to healthcare delivery, and billing codes during the pandemic, along with major updates to the E/M documentation guidelines have created a ripe environment for government-contracted auditors. But you have the right to challenge auditors. Take steps now to establish your culture of compliance.

Could 2021 become an audit-heavy year? Regulatory compliance and audit defense expert Sean M. Weiss, CHC, CMCO, CEMA, CPMA, CPC-P, CMPE, CPC, CMC, CMIS, CMOM, Partner, Vice President of Compliance for Doctors Management, predicts more scrutiny and audits resulting from last year’s healthcare upheaval.

“It’s a possibility, but it's not too late to get things straight,” he says. “Despite the ongoing PHE, payor audits are and will continue to ramp up. TPE, MAC, OIG, RAC, MIC, CERT and SIU, as well as other types of audits, are in full swing.”

Some compliance experts are already knee-deep in investigations and audit defense work. Sean predicts problems will continue for providers and health systems based on the surge in telehealth services and COVID-19 waivers extended during the Public Health Emergency (PHE) to help providers operate more efficiently. But there are steps that medical office managers and auditors can take now to build a better case for the future if errors/oversights are flagged in an audit.

“It starts with research: locating specific payer policies, utilization guidelines, participation agreements, contracts, or any other published guidance documents when you perform audits," he says. "The more you know, the more you will be able to stand your ground! It all comes down to establishing a culture of compliance.”

It is vitally important for all medical offices to be prepared by learning audit terminology and what auditors are looking for, he says. "Understanding the criteria, details, and differences between things like disclosure and refund processes will help build your case. Also critical is knowing how to perform a self-audit and build a solid defense, with authoritative guidance from peer-reviewed papers, specialty society publications, and guidance from the AMA and CMS."

Sean has protected thousands of physicians, medical practice groups, hospitals, and medical management societies from undue penalties. He says that you can and should challenge payers that try to claim your office’s lack of knowledge or obligation thereof.

“You have the right to request that they produce the binding guidance documents that place the responsibility on you or your providers.”

Sean just completed a recorded session with insights to help you navigate the technical jargon and gain confidence when faced with an audit. He discusses things like:

  • How to distinguish between disclosure and refund processes,
  • How to research and locate payer policies, utilization guidelines, and agreements
  • Where to go for authoritative guidance such as AMA, CMS, and specialty publications
  • How/when to challenge payers

And, if you need professional help, he will tell you how you can bring a professional auditor onsite to guide the process.


Join a special encore presentation with Sean Weiss at noon July 7 and learn from examples drawn from his vast experience.

Learn More & Register Now

Topics: Practice cash flow, payer contract, carrier contract guidelines, medical office, medical billing, financial management, auditing

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