Protecting yourself from an adverse federal audit.

After reading the OIG's Work Plan with its focus on Behavioral Health in 2005, many providers are wondering what they can do to protect themselves from a federal audit or investigation. The answer to that question depends entirely on the time frame being considered.

For past services there is little providers can do now that will provide any additional protection. The services have been provided and documented. They have been billed and likely paid. There is really no safe way to go backwards and "catch up" on documentation or modify descriptions of services contained in the medical record. If a case manager took a client to the mall to shop for birthday cards and billed Medicaid, there is little that can be done to dress this up in mental health colors and expect a pass by an auditor. In fact changing the medical record in any way after notice of an audit can be very dangerous legally and should be done--if at all--only under the oversight of your healthcare attorney.

So, stop looking backwards and turn the attention of the organization forwards. Actions taken now by providers can provide protection for current and future services. Providers are in a much better position to argue for leniency if they have turned their operations around and services are being guided by stricter adherence to regulation and by a vigorous compliance program. Two of the areas that deserve the most immediate attention by providers are the content of services and the quality of the documentation of services being billed to the federal healthcare programs.

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Medical Record Reviews

Most compliance professionals suggest that providers move from retrospective to prospective auditing and monitoring of those services that will be billed to a third party. Prospective audits look at services while they are still in the billing queue or before they have even made it into the queue not after they have been billed and/or billed and paid. By doing prospective audits providers do have an opportunity to: pull services that should not be billed because they do not meet service definitions (e.g. the shopping trip to the mall described above); make corrections to ensure that the documentation is clear about the medical necessity of the services provided and other service content issues; ensure there is a current treatment plan ordering the service; and, make sure the documentation has all required elements according to federal and state regulations.

There are various types of prospective reviews that can be done by providers. Some of the more common ones are:

* A review of each progress note to ensure that documentation exists …