When a payer or health plan calls your practice and requests records or requests an on-site visit to review charts, follow this guideline:
- Be professional at all times. Audits can be nerve-wracking and can be a drain on internal resources, but there is always something to be learned from the process.
- Ask for the request in writing, to include the names of the patients whose charts will be accessed, the dates of service covered under the audit, the name of the auditor, the specific reason for the audit, what the result from the audit will entail (warnings, sanctions, grading, etc.) and if the result will be published in any form anywhere. Request that the specific information culled from the audit be shared with your practice in a usable form.
- Review your contract with the payer for any language related to the payer’s rights to access information, the description of the information, and any payment due to the practice for the labor and resources used in producing the records. Check with your state insurance laws for any information regarding such requests. Note that Medicare Advantage plans do not have contracts with practices, so you do have the right to charge for the labor and resources necessary to produce records.
- When the information arrives from the payer, confirm that the patients named in the audit have records in your practice.
- If the explanation for the audit is unclear, request more in-depth information in writing.
- If you are satisfied that all requirements are being met by the payer, schedule the audit, or arrange for records to be sent. If coming on-site, arrange for a quiet place for the auditor to review records, preferably close to you so you can observe, answer questions and ask questions.
- Review records or charts requested by the payer and be sure to remove any documentation that does not specifically refer to the dates being included in the audit. Do not give the entire chart to the auditor,
- For practices with EMRs, print the appropriate documentation for the auditor if they request an on-site visit. Do not give the auditor access the system, as their permission to review records is limited.
- Analyze the feedback received to improve any areas needed and document your effort as a part of your compliance plan. Have all practice employees sign off on any compliance plan updates.