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 2025 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.
“It’s a possibility, but it's not too late to get things straight,” he says. “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. 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 recorded insights during the pandemic to help practices navigate the technical jargon and gain confidence when faced with an audit. Highlights include:
- 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.
Sean Weiss recorded a learning session on audit webinar that includes real case examples drawn from his vast experience.
