Who Can It Be Knocking at Your Door? Are You Prepared?

by  Sean Weiss
September 9th, 2016

The truth is you can never be fully prepared when a Special Investigative Unit (SIU) from Medicare or Medicaid shows up unannounced. With that said, you can use this tip to help understand what your obligations are and how to act to ensure it is as smooth a process as possible and does not lead to your being booted from participating with The Centers for Medicare and Medicaid Services (CMS). I have followed a very simple business philosophy throughout my 20+ years in this industry as outlined by Sir Henri Deterding: "There is a master key to success with which no man can fail. Its name is simplicity. Simplicity, I mean, in the sense of reducing to the simplest possible terms every problem that besets us. Whenever I have met a business proposition, which, after taking thought, I could not reduce to simplicity, I have left it alone."

Too often we work against ourselves, over thinking situations and running through all of the possible downsides that could present themselves rather than focusing on what it is that's in front of us and finding the best way to get from point A to point B. That is really what

an audit and its findings are... how they got from A to B. Our job is then to figure out if the audit findings met all of the steps between point A and point B.

Receiving a letter from a carrier, investigatory agency or private payer is stressful enough. But what happens when someone shows up at your door with a business card and a letter and wants everything right then and there? This is a situation that is becoming more familiar and one that if you are not willing to accept that this can and possibly will happen to your practice, then the outcome will have serious adverse effects.

During the last month, we at DoctorsManagement have had multiple practices reach out to us for support and guidance because they had someone show up from AdvanceMed (ZPIC) and/or the Special Investigative Unit (SIU-Medicaid) demanding access to medical records, provider schedules, sign-in sheets, and imaging studies. The organizations were varied in geographic location, size and specialty, so there is no real detectable pattern as of yet.

The following are things you can do to ensure you are feeling good about your outcome with one of these groups:

codes, modifier application, ancillary services, minor procedures, time as a controlling factor, etc. inaddition to E&M services. The purpose of a provider's documentation is to "paint a clear picture for the auditor who will be reviewing the information at some point but more importantly to ensure that any provider assuming the care of the patient can do so in a safe and prudent manner." In addition, ensure that documentation exists and that is complete and legible, ensure that anyone making an entry into the record is logged for identification purposes, ensure all notes are signed, and validate supervision of NPPs and whether or not incident-to or split/shared guidelines are met.

Even following the steps above does not ensure you will never be audited, but when it does happen at least you know where you stand. When an unannounced site review takes place, the following are steps you should take to make the process less arduous:

"Everything should be made as simple as possible, but not simpler"- Albert Einstein

By now, you can see that I like to approach things simplistically. While an unannounced site visit can be a very nerve wracking experience, taking a simple approach and following the suggested steps above can make the experience less stressful and complicated for all involved. In addition, implementing proactive measures such as performing routine audits, and understanding your true risk can greatly reduce the level of stress and worry should an onsite visit to your practice occur.

Who Can It Be Knocking at Your Door? Are You Prepared?. (2016, September 9). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/who-can-it-be-knocking-at-your-door-are-you-prepared-31741.html

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