There are not many things that create more anxiety within the behavioral health clinician community – especially when we take health insurance for payment – quite like the looming fear of being audited.
No one wants to get a letter from an insurance company requesting records. If you believe social media, you have heard of people who have been in practice for decades who have never been audited by anyone for any reason at all. And there are other folks who have been audited by everyone several times for “no reason at all”.
Questions about audit are probably the number one topic I get questions about from my consulting clients. Most of my clients, at some point in our conversation, want to know about audits, what they might expect to experience, and how they will go.
Audits can be incredibly anxiety provoking. Even the word alone can trigger all sorts of negative thoughts in us.
Of course, sometimes these audits are meant to be anxiety provoking, but most of the time it’s just our own anxiousness that is driving those feelings. It often comes from our sense of not quite being sure we’re prepared to be reviewed.
First off, and its very important to remember – record audits are not a single process. There are audits happening for any number of reasons, and the reviews are attempting to accomplish very different things through their processes.
Some are, indeed, focused on claims – do your records show evidence you did what you billed for, and you have a reason to have billed for it.
And there are audits for all sorts of other things.
Some are service review audits – these are particularly for Medicaid, which is looking to make sure you’re following some basic rules around service quality reflected in records. Some of these can double as claim reviews, depending on the State.
Some audits are related to quality of care – a review after something “goes wrong” in your practice.
Other audits are more focused generally, as they relate to how services are being delivered across a health insurance plan. These will be most notable because they will ask for records generally without listing any client names and might even allow you to redact records a bit.
And still other audits are primarily about the insurance company and not about you the clinician really at all. The so-called “risk adjustment” audits for Medicare Advantage and Marketplace plans. These typically only request one treatment record for the review.
The important thing is, when you get a letter, take a deep breath and Read It. Then read it again. Do not wait 30 days to open the envelope. Read it the day you get it – or maybe the next day. You really want every day you can to respond to the letter, and the letter will have a due date for whatever they are asking for.
If you’re not sure what they are asking for, have someone else read it too. Try to understand the nature of the request so that you can respond appropriately. The nature of the request – the why – is usually stated in the first or second sentence of the letter.
If you get a letter, and it mentions “claims” in the first couple of sentences, it is one of “those” letters.
Don’t panic and start preparing. Review what they are asking for and understand every blemish before you submit stuff. They will be focused on the progress notes, but always submit the initial assessment materials (intake questionnaire, assessment documents, initial assessment tools, etc.) and treatment plans. If you can’t because they were not the insurance company when that service was delivered, make sure you note that in a cover letter and write a summary of the information in a separate document.
Even the scariest audits don’t have to be all that scary if you’re prepared for it. On social media you’ll hear stories of clinicians who have been audited multiple times and who have never had to pay back a dime. I have audited many records that have passed at 100 percent.
Also, keep in mind that, for commercial insurance, most auditing is arbitrary and at random, while most Medicaid auditing is required and sequential, but not all States audit significantly for Medicaid.
At the end of the day – don’t be afraid, be prepared. Nothing stops the process more than having decent records to start with. But, of course, I always say that.