BC Advantage - 2013 Issue 12
Audits: What's the Big Deal?
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Article Overview
This article discusses audit exposure in healthcare reimbursement, with emphasis on medical necessity, documentation quality, evaluation and management coding considerations, and compliance program fundamentals. It is aimed at medical practices, coders, compliance staff, and consultants who want a broad understanding of how audit findings develop and what areas of practice management are commonly scrutinized. The article also references government audit activity and fraud-and-abuse enforcement trends to frame why these topics matter.
Why This Topic Matters
Audit activity can create repayment exposure, denials, and compliance risk for healthcare organizations. Understanding the article’s scope helps readers evaluate whether they need guidance on documentation, medical necessity, internal review processes, or broader compliance planning.
Article Sections
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How Medical Necessity Impacts the Outcome
Introduces the article’s focus on audit risk and the role of medical necessity in reimbursement review. Also frames the discussion within broader industry and enforcement trends.
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Audit activity and recovery trends
Summarizes reported recovery audit activity and discusses the larger environment surrounding overpayment and underpayment reviews. Provides context for why practices monitor audit exposure.
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Using reports and internal review to identify risk
Describes practice-level analysis approaches used to locate vulnerabilities and improve readiness for review. Covers internal evaluation, external support, and confidentiality considerations.
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Medical necessity and documentation
Explains the article’s emphasis on documenting the basis for care and the relationship between medical necessity and audit outcomes. Discusses broad documentation themes without delving into specific coding decisions.
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Evaluation and Management coding considerations
Reviews broad E/M documentation themes, including history, examination, and medical decision making. Addresses the general compliance concerns that arise when service level selection is not well supported.
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Compliance program elements and enforcement risk
Outlines general compliance program components and the role they play in reducing enforcement exposure. Mentions governance, training, audits, reporting, and corrective action at a high level.
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Healthcare fraud and abuse statistics
Presents government enforcement and recovery figures cited to illustrate the scale of healthcare fraud oversight. Serves as supporting context for the article’s compliance message.
What You Will Learn
- How audit activity can affect healthcare practices
- Why medical necessity is central to audit outcomes
- What broad documentation areas are commonly reviewed
- How E/M service selection is tied to supporting records
- Which compliance program elements are discussed as risk-reduction measures
- How fraud-and-abuse enforcement trends are used to frame audit concerns
Who Should Read This
- Medical coders
- Compliance officers
- Physician practices
- Practice managers
- Healthcare consultants
- Auditing and appeal professionals
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