Why Become a Medical Auditor (or, Better Yet, A Certified Professional Medical Auditor)?

When I began my career in coding, each insurance company had its own billing form. Often, the insured would bring the form with him at the time of visit, to be filled out and submitted to the insurer. I would take the e form, hand-write all the pertinent information, and submit it to the insurance. We would wait 90 to 120 days to get the reimbursement before calling the payer to see if there was any issue with our claim. I learned quickly not only to make sure my DSM-III and CPT® coding lined up, but also to make sure I knew which boxes were required for which insurance company to insure accurate payment within this three- to six-month time frame.

Fast forward to today. We now use one consistent form for physician or practitioner services, the CMS-1500, and we usually file electronically. The forms are not only uniform, but most insurance companies are uniform in their requirements as to which boxes need to be filled out and what information needs to be provided. This is a much better system for ease of submitting claims and getting paid, but today's claim filing is also a more complex system as far as coding rules and regulations. For instance, today's coders and billers must know how to navigate computer software systems and the  internet, download and interpret reports, and address and fix errors in a timely manner, while also understanding the different rules and regulations for Medicare, Medicaid, and each private payer.

In response to this complexity, physician's offices must protect themselves against accusations of fraud and abuse. In my unofficial perusal of the local and national job ads, I see that most of today's physician's offices prefer to have a certified coder on staff because this offers some measure of protection for the provider.

The AAPC now has taken the coding profession to the next level with a newly-offered certification, the Certified Professional Medical Auditor (CPMA). The reasons to become a CPMA are as varied as the people who decide to pursue the certification; but most of us are interested in protecting our medical practices while increasing our net worth and furthering our marketability. Coders who decide to pursue furthering our career with the CPMA become a more valuable asset in today's changing healthcare arena. Medical auditing is a crucial part of an overall compliance program set forth by the Office of Inspector General (OIG) as part of a compliance program (Federal Register / Vol. 65, No. 194 / Thursday, October 5, 2000).

A voluntary compliance program is no longer an option, but is now mandated for physician services with the passage of the Patient Protection and Affordable Care Act of 2010. Providers must adopt a compliance program as a condition of their Medicare enrollment. What this means to the CPMA is that our services will be more valuable than ever. A CPMA familiar with compliance issues will be in greater demand as practices make sure they are in line with the requirements of the OIG and the U.S. Department of Health and Human Services (HHS), while also understanding the rules and regulations of Medicare and Medicaid.

An advantage of having the CPMA certification over just having a Certified Professional Coder (CPC) certification is that the CPMA is a profession that is not set to be outsourced at this time. Even though we can audit records remotely, the need for hands-on feedback and high-level auditing skills is great in the medical field. CPMA's have a good understanding of compliance guidelines, coding concepts, the medical record, and how to interpret results and communicate audit findings effectively. I highly recommend anyone considering getting a core credential to obtain their CPMA.

There are several ways to obtain your CPMA. The AAPC offers links to vital information to help you study for the core exam, as well as information for the two day prep classes. Either one of these options is good but I would suggest attending the class if you are not strong in compliance issues. The information the AAPC offers through their links to auditing and compliance resources are very helpful; it does help if you have prior understanding of compliance and can navigate to find what is needed to fill in the gaps of your knowledge. On the flip side, the advantage of the in-person class is that you will have hands-on help as well as the benefit of the printed material; this will help narrow down the focus of your studies.

Whatever option that you choose, I strongly suggest getting Deb Grider's book, Medical Record Auditor, Second Edition, as a valuable companion resource. This can be ordered online at the AAPC while you are ordering your class (or just the test, when you're ready).

The demand for CPMA's will increase as more physician's offices realize the value of our services and the protection that they need when faced with Recovery Audit Contractor (RAC) audits, payer denials or just making sure they are compliant before any type of outside audit hits. The investment you make in your future today by becoming a CPMA will pay dividends for many years to come.

Susan Reehill, CPC, CPMA, CEMC