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EDITOR’S NOTE: A call-in by a listener to Monitor Mondays last Monday has prompted this special bulletin.

So you know you are audited, you even know they are RAC audits, but what are you doing about it? How are you tracking what is audited, recouped, overturned, etc.? It is imperative that you are tracking every facet of every audit.

When you receive a request for records from a carrier, the concern should not be how quickly can you pull the records and get them back out of the door until you first do your due diligence of the request. Let’s break down the audit review process and what procedures should be in place for each process. Every audit, even every record request, should be handled the same way, as they all affect the practice reimbursement on some level.

So let’s start at the beginning and work our way through.

You receive a letter requesting records for review. Upon receiving the request, the following should be identified and tracked as a standard for effective tracking:

  • Who is requesting the records
  • The number of records being requested
  • The time frame of the request and the provider targeted
  • What prompted the request/review
  • The due date of the records
  • Outcomes of the review
  • Appeals and follow-ups

While a tracking software system for ongoing monitoring and analysis is a convenient option and would help with each of these points, there are other methods that may be used, including a simple Excel spreadsheet. The key to sustaining and maintaining reimbursement for services performed rests in the tracking. Records request should be tracked first and foremost as a method of ensuring reimbursement. Providers perform the work of the services billed, along with creating documentation of the service, and, at minimum, being paid for the service should be our hope. Therefore, developing a plan to ensure adequate follow-up and future analysis of your audits and reviews is a required core component of a practice.

Monitoring who is requesting the records is imperative, as this could identify why your provider or practice is being scrutinized. Frank Cohen, leading healthcare statistician and analyst, has noted on his Compliance Risk Analysis process the noted risk analysis types by review break down thusly: The OIG audits target on a time element, while the RACs focus on an RVU review, and the carriers focus on a specific procedural outlier review. Therefore, tracking who is requesting the records can help to best identify which qualifier, RVU/time/procedure, is identifying your provider as an outlier.

The number of records being requested will help determine the qualifications and considerations of how broad a review is being performed on the provider. Random samplings are imperative to a valid audit, based on the volume of the providers’ use of the targeted service for review. The size of the request could help identify the type of review. Not tracking this information does not allow for the realization that the review of the service is growing in depth and is therefore a greater concern to the provider. Noting the number of records and whether their sample is valid statistically can be a point on which appeals could be formed.

The time frame from which the records are requested should be part of the tracking process. You should take the records request/audit information and compare it to the utilization patterns of the provider’s billed service during the same time period. This may help to further identify the scrutiny. Obviously, the provider who is subject to the specific request should also be tracked. There are certain providers that may have unusual billing trends due to the dynamic patient base, and then there are some providers whose billing trends are uncharacteristic of their specialty/peers due to inappropriate billing/coding processes. Tracking helps you better identify which providers you should continue to focus on through internal review processes and education.

Track the reason the payer/carrier/review affiliate initiated the records request. If Dr. X is receiving multiple requests for services based on medical necessity, then increased efforts should be made by internal compliance to perform more reviews for validation of this trending. Oftentimes, facilities and practices note that they are receiving records requests, but when we ask why, they are unsure, and unsure as to how long this has been a target for the provider. Not all requests specifically spell out what is being reviewed, and often the reason listed for the review may not even encompass the full evaluation. However, not tracking this factor at all will inhibit you from being able to monitor any trends.


One of the most important points on the review letter is the due date of the records request. While most facilities and practices show no problem with noting this and adhering to the timeliness, this article would be remiss without mentioning the deadlines associated with this point. Use the time you have been given to its full length by reviewing the documentation and the billing. It is not appropriate in any circumstance to “correct” documentation, but addenda (properly orchestrated) or letters of clarity may be of value with the submission of the information for review. By reviewing the records in this way prior to submission, you may limit the payer review or the need for a future appeal.

Are you tracking your ROR (return on review)? Facilities and practices should be monitoring what services are immediately paid upon presentation of the records, and which ones are denied. Once the facility or practice has received denials or upheld reviews, the documentation that was analyzed should be reviewed and understood in order to use the process to educate about any deficiencies that need to be modified on future services. Additionally, it will identify records in which an appeal should be formed and submitted when there is a disagreement in the reviewed interpretation.

We hope that the last process involved is the appeal process, and most certainly we hope that an escalated appeal is not required. Many facilities and practices will accept the findings of an audit and not appeal, but why would a facility or practice not appeal if the provider did the work and documented the service accordingly? In many ways, not appealing is like saying yes, we did it wrong—so always be sure to appeal when the documentation and billing support the need for an appeal. Then track the appeals, not only to ensure the individual claim payment occurs, but also to note how many of the appeals are overturned and by what carriers and review organizations as well.

Your facility or practice may already have a good grasp on the tracking of audits and reviews, but what about the tracking and analysis of recoupments? This is especially noted in instances of RAC involvement. A listener submitted a question to Monitor Monday last Monday inquiring if there has been a trend of RAC audits that have been overturned on appeal, but with the CMS carrier still recouping their payment and even tacking on the interest penalty. Unfortunately, this appears to be a growing and noted trend between the two, with finger-pointing as to whom the error is being made by. Facilities and practices that are not tracking these points have no true overall vision of the retention of their reimbursements. Clinicians provide care and work within the confines of the expectations of the payer system, and you might expect that once the work of receiving the claim payments is done, the work is done. However, as we move through these changing times in healthcare, it will become more prevalent that equal work is required on the back end of the claims payment to ensure accurate retention of payments.

About the Author

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies.

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