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Career Coders Consulting/Auditing Services

Career Coders offers a variety of consulting and educational services.

Many services can be performed onsite or online.

Physician Audits

Role of Auditor
The role Career Coders independent auditor is to objectively and neutrally examine, analyze and review all date in accordance with appropriate federal and state guidelines and applicable insurance billing policy. Career Coders independent auditor assess operational, billing, coding and compliance workflows and recommend best practices as applicable to the healthcare, billing, coding and compliance environment. Any internal protocols, mechanisms, and standards that are not in accordance with federal or state law, are considered ethical and/or legal risks to this independent auditor and will not be considered or incorporated into audit findings.

Purpose/Objective of Audits
The purpose and objectives of audits is to promote and educate adherence in the performance evaluation of all providers/NPP documentation. Providers and NPP’s are bound to comply, in all official acts and duties, with all applicable laws, rules, regulations, standards of conduct, including, but not limited to laws, rules, regulations, and directives of the federal government and the state regulations of the Medicare Contractor, Fiscal Agent (FI) to include rules policies and procedures of the physician/practice written compliance plan. Medicare guidelines are followed by a majority of insurance payers.

Scope of Services
Career Coders, LLC recommends conduct ongoing evaluations of compliance auditing processes involving thorough monitoring and regular reporting to the officers to the appropriate individuals of the facility/practice.

What Information do we audit?

Providers are given individual reports to include any discrepancies in documentation, coding and billing, medical necessity as well as recommendations to assist in improving any of the above. A final report of group and individuals is distributed to the compliance officer, medical director and others designated by the group practice for any concerns that need to be addressed.

Career Coders also recommends and can assist in developing an Auditing Compliance Plan. This type of plan focuses on physician documentation for providers to follow and assist them in proper documentation. Auditing can have grey areas and this type of plan will make sure everyone is following the guidelines correctly. It will help identify any possible risk areas for providers such as unnecessary services, medical necessity and of course the most important is make sure the documentation is correct and complete.

Billing audits can also be requested to identify reimbursement issues that help identify why the practice may have high accounts receivable.

Areas that can create high accounts receivables are claim denials and collection of overdue payments by patients or insurance company. Accounts receivables should be worked often and in a timely manner and often. Many insurance companies have timely filing issues and if denials and appeals are not worked within the time period set by the insurance guidelines these can add up to huge losses for a practice. Typically this is the number one reason physicians have additional write-offs. Very important you have managers that are monitoring denials and write-off’s closely to make sure these claims are being performed in a timely manner and there are processes in place for these workflows and processes. AMA quoted that over 70% of denials are paid on resubmission. Resubmission and working these claims can make a difference in the practice reimbursements.

Problems we experience in billing offices is the lack of manpower to work many of these denials and appeals. Overstaffing can create cost and understaffing can create loss of revenue, it is a difficult decision. Keep in mind it all these processes are not just billing department but includes all departments. Is the front desk collecting all the information and entering correctly, collecting payments and copays at check in, nursing and other ancillary staff entering all procedures performed, and is documentation and coding appropriate? These are all important steps important for reimbursement and submitting clean claims. If we are missing a spoke, the wheel can’t turn.

Insurance costs have also increased higher accounts receivables due to higher deductibles or patients unable to afford insurance. Doctors are the last person to get paid because patients will pay their mortgage, buy groceries and other necessities first, and the doctor get paid last.

Another area of concerns are inappropriate or lack of waivers be signed by patients. Medicare patients should sign form Advanced Beneficiary Notice or ABN if there is reasonable knowledge the service may not be paid for. ABN’s must be filled in their entirety and signed by the patient BEFORE the services are performed. It is considered FRAUD to have all Medicare patients routinely sign an ABN. We also recommend a standard practice waiver for those non-Medicare patients to inform the patient of services that may not be covered. Is it necessary? No it is not, but you can save the practice, patient and billing employees less hassle by informing patients before services are performed.

When was the last time you REALLY looked at your insurance contracts?

Many of these contracts renew every year but are never fully reviewed by the practice or provider. Don’t be afraid to negotiate your contracts. One mistake I feel many practices make is not getting the billing department involved. The billing department can assist in giving details of those insurance companies they struggle with and know the issues such as problems with certain diagnosis codes, procedures and I think most important is modifiers the insurance companies refuse or do not use appropriate as defined in the CPT book. This information can be powerful in re-negotiations of contracts.

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