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How To Make Your Next Medical Record Audit As Painless As Possible

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Most physicians and their staffs find medical record audits a painful necessity of the modern age, but it doesn't have to be that arduous an experience.

Chart audits are valuable tools for identifying lapses in care or inconsistent treatment procedures that might otherwise go unnoticed. They're also critical when it comes to making sure that you're billing process is accurate—which directly affects your reimbursements. They're also necessary for legal protection, since both issues with patient care and incorrect billings can expose you to legal liabilities that are better off being avoided.

Here's how to prepare your staff (and yourself) for the next audit:

Make Internal Auditing a Routine Process

You probably tell your patients that small changes, consistently maintained, can produce great long-term results. Well, that's something to keep in mind when it comes to paperwork, as well. If you create an office culture that pays attention to detail on a daily basis, it'll be a lot easier come the next audit to pull out all the documentation. 

Make sure that the following things are done on a scheduled basis:

  1. A random sample of billing statements should be pulled for review to look for mistakes that could indicate a lapse in training or problems like over-coding and under-coding.
  2. Pull a selection of patient charts, and have someone review them for any missing information or inconsistencies, like missing interpretations of test results or diagnoses that aren't supported by the notes.
  3. Review current educational requirements and training needs of your staff to make sure that you stay in compliance with new codes and guidelines.
  4. Summarize your results, and communicate them to your staff so that everyone is aware of areas that need improvement. 

If you don't have the time to do the audit yourself (and you probably don't), it's time to think about hiring someone for the task. That might be more productive than relying on your staff to catch and correct errors anyhow.

Give Plenty of Prep Time for the Next Audit

The next time you're faced with a formal records audit by the Centers for Medicaid and Medicare Services (CMS) or another entity, your audit will go smoother if you do the following things:

  1. Make sure that you have a specific policy in place for responding to audit requests and that all staff members know who should be alerted.
  2. Assign one staff member (preferably the records manager) as the contact person for the audit. Have that individual talk to the auditor to find out what has prompted the audit. If it's the result of a patient complaint, for example, that can guide your expectations, which would be much different than you might have if the audit was just the result of random selection.
  3. Have your records manager pull the documents needed for the audit in advance. If you're using electronic records, find out what reporting tools your particular system has and use them. (It's likely to have data aggregation tools you aren't even aware exist, so call your vendor for directions.)
  4. Make sure that your office looks as professional as possible. While it might seem superficial, appearances do count. If you have expired samples sitting around and chaotic-looking workstations, that's going to give the auditor ideas that you aren't paying attention to details.

The more your staff comes to view audits as part of the routine rather than an interruption, the easier they'll become in the end. Good communication and clear expectations are key to making that happen.

For more information, talk to companies like Clarity Pharma Research.