Minimize the damage an audit can create

As many of you may know by now one of the main areas our firm specializes in is audit representation for providers who are going through an audit or have gone through an audit and are now in need of representation to minimize the damage an audit can create. There are many who will read this blurb and dismiss it and then there will be some who read it and simply will not believe it.

However, If you are working in a group where your providers are not fully aware of the guidelines for selecting levels of Evaluation and Management Services or they have simply chosen to ignore the guidelines it is time to get them educated before an "Audit" happens. It's no longer a matter of if an audit happens, it is now when an audit happens will we be able to survive! Currently the Department of Justice has taken the stance that they no longer have to prove the intent to abuse or defraud they simply have to show that errors exist. Below are three areas where providers are being prosecuted in health care. These are part of The False Claims Act 31 U.S.C. 3729-3733 (for a complete listing of this statute visit our resources page at and click on resources)

1) Knowingly ­ has knowledge the information on the claim is false (up-coding)

2) Deliberate Ignorance ­ deliberately chosen to ignore the truth or falsity of information on the claim (ignoring provider update bulletins)

3) Reckless Disregard ­ pays no regard to whether the information on a claim submitted for payment is true or false (billing functions delegated to untrained office personnel)

Audits do not have to be large gargantuan numbers to reek havoc in a group. Fines from $50,000 to $250,000 are enough these days to put a major dent in a medical practice if not to shut the practice down altogether. What most group practices do not realize is that the monies are paid to a Tax ID number so when a carrier recoups it comes from the Tax ID number to which it
is paid. Sure the individual provider bares the brunt of the blame but the manager and the coder can also potentially face sanctions. This is why it is so important to take compliance seriously. If you do not have a compliance program in place it is time to develop one. There are many places where you can get the tools you need to build your OIG Compliance program for free.
The resources page on The CMC Group website is a prime example of where to go to get free resources.

Recently CMS and the OIG have stepped up their efforts on combating fraud and abuse. Identifying "outliers" or "aberrant" coding patterns has never been easier for them. Statistical tracking, one of the methods for identifying areas of potential risk has been done for many years, however, now more emphasis is being placed on what the numbers actually mean.

The Iowa Medical Society recently released the latest numbers for all specialties. This is available for download on The CMC Group website. Simply go to and click on the resources tab and then on compliance to download the FY 2005 coding curves.

Don't take chances, the best defense is a strong offense. Run a productivity report from your Practice Management System (PMS) and compare your E/M numbers to those provided you on the Excel spreadsheet.

Sean M. Weiss is a Senior Partner and Principal with The CMC Group, a full scale medical consultancy and legal research firm based in Atlanta, GA. To learn more about The CMC Group, its principals or consultants visit them at or contact them at (888) 262-8354.