Deliver Results Effectively - How to educate providers

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:

  1. 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.
  2. 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."
  3. 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!
  4. 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.
  5. 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.
  6. Never tell a provider they are wrong: I believe this one is very self explanatory.
  7. 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.
  8. 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%."
  9. 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.
  10. 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 trust.

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 or at