Deliver Results Effectively - How to educate providers
August 05, 2014
By: Sean M. Weiss, V.P. and Chief Compliance Officer
"Doctor, your documentation does not support the level of service you billed
to the insurance company..." These are the dreaded words every auditor delivers
and the words every provider despises hearing. But, what if we as an auditor
are wrong; what if the level is supported based on complexity, but as non-clinicians,
we were not able to make the correct assessment?
Auditing should be looked at two (2) ways: as a qualification and quantification
process. According to Merriam-Webster, qualification is "a special skill or
type of experience or knowledge that makes someone suitable to do a particular
job or activity." In the world of auditing, we have special skills that make
us qualified to review medical documentation and determine whether the level
of service billed is correct, but correct based on a quantification process.
Again, according to Merriam-Webster, quantification is "to find or calculate
the quantity or amount of (something)." Hold your thoughts and I will explain
where I am going with this.
For 20 years now, I have been known throughout the industry as a compliance
expert and someone who focuses solely on writing policy and procedures or representing
clients in appeals (ALJ, MAC, or Federal Court). However, I have been serving
as the Director of Coding for one of the Nation's largest health systems since
2013 with more than 105 coders/auditors, 2,000 providers, and a very demanding
Board of Directors. Just like many of you reading this article, I grew up in
this industry as a coder (first certification in 1997), so when I write about
these types of issues, I am speaking from personal experience.
In my weekly travels (which by the way on June 30th 2014, for the third year
straight I will hit Diamond Medallion Status at the half way point of the year
on Delta), I hear providers talk about how the last audit they had was a colossal
failure because the auditor/coder tried to tell a clinician what defined low,
moderate, or high Medical Decision Making (MDM). As an auditor/coder, we possess
a very specific set of skills, but unless you have RN, LPN, PA, NP, MD, DO,
etc., your skills end at arguing with a provider about what truly defines a
level of decision making, unless of course, you are talking about it from a
pure "bean-counting" perspective.
The 1995 and 1997 Documentation Guidelines are just that: guidelines. They
are an attempt to quantify various levels of complexity by assigning point values.
They are not absolutes and they should be approached with the utmost caution
by anyone attempting to audit or code select on behalf of a provider. What drives
many auditors/coders to select a level of service that differs from a provider
is that providers go through a complex process of arriving at a plan of care.
They have to take into account differential diagnosis, chronic systemic illnesses,
prescriptions, family history, and a whole host of other items to arrive at
a course of care for a patient.
Nothing drives a provider crazier than when an auditor/coder tells them that
because there was no Rx written or they did not order test(s), the level of
service is not supported. Believe it or not, it takes more effort and thought
process to do nothing than it does to put pen to paper and give the patient
something they may or may not benefit from. Yes, in the black and white world
that auditors/coders love to live in, you have to satisfy 2 out of 3 in the
MDM to reach a specific level of complexity. However, I am here to tell you
that there is no black and white, just various shades of grey. I spend close
to 150 days per year working various types of appeals or arguing demand for
refund requests on behalf of providers and health systems and I assure you that
when you present before an ALJ and now even at the QIC, the guidelines go right
out the window and clinical judgment stands front and center.
For some reason, auditors/coders take an argumentative and even adversarial
position when having to confront providers about their most recent audit.
So, what I am presenting here is a guide to those tasked with the often
difficult role of providing feedback to providers:
Stop calling them audits: Audit has a negative tone attached to it. I refer
to it as either a documentation review or provider education review because
in reality, auditing is a function done by the IRS or a governmental agency
or someone looking to potentially do harm to a person.
Develop a rapport with the provider: I often begin a session with, "We
are meeting with you today as a way to help you understand threats from the
outside as it relates to your coding and documentation. I am here to provide
you with education as to what the guidelines set forth by The CMS and other
payors have determined support a level of service from a quantification standpoint
and not a true clinical standpoint. Like you, I get frustrated with the guidelines
as they are highly subjective in areas but we have to use what we have."
Identify Lost Revenue: Many providers are so frustrated with the system
that they often opt to down-code their services and in most cases they actually
support a higher level than what they ultimately billed for. Remember, documentation
reviews are not just for risk mitigation; they should be used as revenue opportunities.
This is your chance to be a hero instead of a zero!
Don't play clinician: Unless you have formal medical training in which
you were awarded a degree (MD, DO, NP, PA, RN, LPN, etc.), do not speak above
your pay grade. This is the fastest way to discredit yourself and find your
way out of their office without making any type of positive impact.
When in doubt, seek help: No one knows everything and oftentimes in medicine,
things are highly subjective. If possible, seek out another provider of care
and ask them if they were doing a peer to peer review of this documentation,
what they would score the level of decision making. Now when you meet with
the provider to discuss the results of their review, you have additional documentation
from a qualified individual to help them understand why the level of service
is either too low or too high. If I do not say this, I know someone will take
this above statement out of context and it will turn into a disaster. This
is not a "nanny, nanny, boo, boo, I got another provider to go against you..."
This is an opportunity to say, "I understand your point, and because I am
not a clinician, I sought out an opinion from another provider (without sharing
your name with them) to ask how they would qualify the decision making and
here is what they provided me." Remember, you are not saying they are wrong
or the other provider is correct; what you are saying is that there may be
another way to look at this.
Never tell a provider they are wrong: I believe this one is very self explanatory.
Perform your review using both sets of guidelines: Recently I have seen
more and more health systems forcing providers to use the 1997 documentation
guidelines which, in my humble opinion, make it very difficult to attain the
higher levels of service. Also, keep in mind that providers are not taught
to assess a patient's condition based on elements or bullets. Clinicians are
trained in body areas and/or organ systems so if using the 1995 guidelines
is more conducive to their style of documentation, use those.
If using a compliance accuracy rate, be careful: Showing a provider they
scored a 40% on their review is not something I take pleasure in, so when
I have to do that, I start off by saying something to the effect of, "While
your compliance score is not impressive, don't get discouraged or disenfranchised
because oftentimes, we find one or two minor issues that once I explain them
to you, they will make perfect sense and will be simple fixes to integrate
into your current process so the next time we meet, your score will be 100%."
It is not your job to tell a provider what level of service to select: A
provider selects a level of service for a few reasons. 1) They have no clue
as to what they are doing. 2) They are on an RVU compensation model. 3) They
honestly believe the work they did supports that level because of the complexity
with formulating a plan of care was in-line with that specific level of service.
4) Someone else is selecting their levels of service in which that case we
need to stop that immediately. 5) They are using an EMR/EHR to drive their
level of service in which case you need to shut that feature off immediately
and begin emergency education on what determines specific levels of service.
Offer your assistance in the future: At the end of each provider meeting
that my staff or I perform, we always leave our business card behind and encourage
the provider to email us or send us documentation to review when they are
uncertain as to what level of service they should select. This builds rapport,
confidence in that you're their advocate, and most importantly, it builds
I hope this mini guide serves to help you in your quest to be the best auditor/educator
you can be.
Sean M. Weiss is the Vice President and Chief Compliance Officer for DoctorsManagement,
LLC a full-scale medical consulting, health law, and data analytics firm based
in Knoxville, Tennessee. Sean holds multiple certifications in auditing, coding,
compliance, and practice management. To learn more about Sean or DoctorsManagement
visit their website at www.doctors-management.com
or at firstname.lastname@example.org