Medical audits can be daunting for healthcare providers due to various reasons. The fear or apprehension associated with audits is valid. We all have heard horror stories of doctors losing their clinic and livelihood to an audit. An entire career or life’s work thrown to the wolves, gone before you even have time to process what happened. That is a scary feeling, and rightfully so!

No one wants to end up being one of the statistics mentioned above. The fear of being absorbed into an audit has resulted in an immense amount of time, energy and resources allocated to preventing them. Is this a good thing? Possibly. On the other hand, the risk of allowing this fear consume an unhealthy percentage of your waking hours is a real issue in healthcare these days. Don’t sacrifice your sanity for the sake of security. You deserve to have both in your life. It will take some work, and a willingness to view healthcare from a lens you may not be familiar with.

Part of a successful audit-defense plan is what most everyone in health care is already doing: minimize compliance and regulatory violations. Managing this is usually what drives healthcare providers up a wall. Not only are you monitoring your own conduct, but you’re also responsible for the conduct of everyone in the office as well. You do what is prudent, you educate your staff, you train them, put systems in place to mitigate errors. This is fine and dandy, except you’re dealing with people. Mistakes are inevitable. Welcome to the human condition. What do you do now?

I am not trying to downplay the importance of sound office systems and procedures. They can make or break you. What I am saying is relying solely on avoiding mistakes is not a sound audit-defense strategy. Like most things in life, diversification is the key to success. This is where looking at things from a different point of view is important.

When it comes to audits there are 3 parties involved. The insurance company, the beneficiary (patient), and the provider (you). Insurance companies are vested in protecting their interests. There are ways they do that, but they are severely limited in the way they can approach the beneficiaries. The reason why is because of the Employee Retirement Income and Security Act (ERISA). ERISA protects beneficiaries from the overreaching powers of these insurance companies. Here are the main ways it provides security to your patients.

Fiduciary Responsibilities

Plan fiduciaries, who manage and control plan assets, are held to high standards of conduct under ERISA. They must act prudently and in the best interests of participants and beneficiaries. Failure to do so could result in legal action.

Full and Timely Review

You may have heard of “sample sizing”. A practice that insurance companies implement in an audit, where they take a percentage of you documentation, calculate the error percentage, and extrapolate the error rate over the rest of the claims they chose not to audit. They may do that to the clinic, but by law they are prohibited from doing that to a patient. Every claim in question must be reviewed in full and in a timely manner.

Retroactive Audit Protection

Insurance carriers have 30 days to review submitted claims. Once an insurance company pays for a submitted claim they forfeit their right to retroactively review said claim.

These protections are very powerful, and a good thing for the patient. Wouldn’t it be amazing to operate your clinic under the these protections? What if we told you that you could?

Operating within the modern healthcare environment can be challenging. It requires better ways of addressing the issues we all face. Patient Options aims to provide solutions that help providers operate freely. If you are interested in how Patient Options can help improve your audit defense, click here.

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