Types of Chart Reviews

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So you’ve decided to implement an internal audit program for your practice.  Excellent!  There are so many external parties who can scrutinize your internal documentation, so it is a really good idea to see your practice from their perspective.  An internal audit/review is an outstanding and comprehensive tool.

The first decision is to determine what you want to get out of your audit/review.  Here are some examples of reasons to perform an in-depth, structured, peek into your own medical records:

 · “How are we doing?” review.  This is an excellent way to initiate an internal review process when you don’t have a lot of time, money, resources and have no reason to think there is anything specifically wrong.  Depending on the size of your organization, you select a very small sample:

  •  1-5 records from each provider
  •  representing a variety of services performed by that provider
  1. E/M
  2. Surgery
  3. office procedure
  4. studies
  • every piece of documentation that supports the service

 ·  Formal compliance review.  This process would follow the detailed description contained in the practice’s formal Compliance Plan.  Don’t have a Compliance Plan?  Well, that’s another blog post for another day.

 · “Someone else we know had a problem” review.  A news report or a colleague reports an awful experience with a payor or other oversight entity.  Your initial response is panic, then denial.  Eventually you realize the best path to peace of mind is to perform an internal audit/review to make sure you don’t have any of the same issues in your practice.

 · “We think we have a problem” review.  Somehow it’s been brought to your attention that one area in your operation may have documentation or compliance concerns.  An internal review can be a solid first step in determining if the problem does exist, and to determine the extent of it.

 · “We KNOW we have a problem” review.  At this point, an internal review should only be one component of a larger strategy.  Coordinating efforts with your Compliance department, and potentially Legal counsel, is imperative.  Once you’ve been alerted to a problem, the steps taken and the speed with which you correct the problem can be instrumental in mitigating consequences.

If you’ve got any questions about chart reviews, we can help.  Contact us at sue@habaneroinc.com.

What’s the Difference Between an Audit and a Review?

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So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

 

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call

If you’ve got any questions or need help selecting a chart review method.  Contact us at sue@habaneroinc.com.