Why do you need to monitor and audit your records? Why is verifying that your billing is done correctly so important? Because your life and your livelihood depend on it. An ongoing evaluation process is so important to a successful compliance program. Are your standards and procedures accurate? Is your compliance program working? Are claims being submitted properly?
All of these questions are important to answer. So in this episode of Talking with the Toothcop, Andrea and I walk through the OIG standards for record monitoring and chart auditing. We share some important definitions, my auditing process, and other things that are important to track and monitor. Don’t miss it!
Outline of This Episode
- [1:37] Recap of the last episode
- [4:03] The OIG Auditing and monitoring procedures
- [11:38] Avoid a Corporate Integrity Agreement (CIA)
- [13:08] The definition of an overpayment
- [13:56] Understanding the False Claims Act
- [15:00] Proper charting review and noting
- [19:57] The threshold for fraud is low
- [22:18] Guidance for compliance officers for CIAs
- [29:59] What do you focus on in a record audit?
- [34:03] Other things you need to monitor
- [37:00] Find the time to do audits
- [39:49] The OIG Self-Disclosure Protocol
What does the OIG consider an effective monitoring program?
An audit is one of the best ways a dentist can make sure they’re following proper procedures with their charting and billing. It’s also a great way to find problems and nip them in the bud before they continue. The OIG defines two types of review: (1) A standards and procedures review; and (2) a claims submission audit. I’ve found that a review of standards and procedures is almost nonexistent in most dental offices because most don’t even have written standards and procedures.
The OIG states “In addition to the standards and procedures themselves, it is advisable that bills and medical records be reviewed for compliance with applicable coding, billing and documentation requirements.” Who should be included in the audits? Ideally, the dentist, dental hygienist, and whoever is in charge of billing.
The OIG recommends that you take a snapshot i.e. a benchmark to track that your practice is reducing the number of claims that are overpaid or denied.
What do you focus on in a record audit?
A self-audit is primarily to determine:
- Bills are accurately coded and reflect the services provided
- Charting and documentation is being completed correctly
- The services provided are necessary
Are there any patient safety or qualitative issues? Look at any issues that will pose a problem to your license and your freedom. You’re more likely to be audited on your higher-dollar items, but they’ll often include records for limited exams and hygiene. There are just a few of the things you need to monitor:
- Vital sign records for sedation (document at certain time intervals, time and amount given, etc.). Calculate your time correctly, you will be scrutinized on it.
- Improper coding and billing
- Document tooth number and surfaces
- Make sure you’ve gotten proper consent
- Exclusions monitoring
- Pre-hire screening
You need to be adept at identifying non-compliance from patient intake through submission and payment. Through this process, you can identify what needs improvement. The OIG recommends that you conduct periodic audits at least once per year. They also recommend a random selection of patient records to review (but preferably 5+ per payor and 5+ per dentist). I share the process that I prefer, listen to learn how it’s different (but still compliant).
What do you do when you find problems?
If you identify problems while doing your review(s) you need to determine whether it merits further training and education with staff or changes to your process. If you find risk areas or vulnerabilities, they need to be addressed. The OIG notes that the specific actions taken depend on the circumstances of the situation. It can be as simple as a repayment to a payor with an explanation of the overpayment.
I worked with a dentist whose clinical notes were inadequate to support what was billed. The acting dentist didn’t take x-rays, note what teeth were affected, and didn’t clarify why the work was done. When we uncovered that, they had to figure out how much was paid and return the money.
You have to do that to protect your integrity when you don’t meet the criteria of what is expected of you. When the OIG comes knocking on your door because of a complaint, they can see your history of integrity. It could save your bacon. What do you do if your practice conducts a review and must notify the OIG? What process do you follow? What is the definition of an overpayment? Listen to find out.
Ingrain chart auditing and monitoring into your practice
You have to find time in your busy schedule to do chart audits. You have to do this. It’s not that difficult to create an audit checklist. You can train your staff how to conduct an audit and assign each of them 10 records to go over. Have them report back to you with the feedback you need to reduce your number of inaccurate claims.
I also recommend auditing some of your own records—and be tough on yourself. Allow yourself to be your own worst critic to get better at charting. If you find a problem, fix the errors with that record (with a note—do NOT change the original record). Do some additional snooping to make sure it’s not a systemic problem. Dig until you find more and figure out how to report it.
Compliance is a scale. It might not be possible to hit 100% compliance. But my goal is to get you to a higher percentage on that scale. It’s about putting systems into place to help you sustain positive changes long-term. If you’d like one of my sample checklists, shoot me an email! We cover this topic in-depth, so for more detail, listen to the whole episode!
Resources & People Mentioned
- OIG Compliance: Auditing and Monitoring
- OIG Self-Disclosure Information
- The Next Generation of Corporate Integrity Agreements
- Third-Party Medical Billing Compliance Program Guidance