What are the Auditors Looking For?


There are two major targets for basic and unannounced audits that affect practices with significant fines and penalties.  While there may be specific flags other than these that caused an audit for different practices, these two items account for the most significant penalties.  We are informing you because these are two processes that you can easily correct.


The two major targets of an Audit are:

Interpretation and Reports


We find that about 80% of doctors are not doing, or not doing properly, their Interpretation and Reports.  Many doctors doing a report had non-compliant reports.  We have seen articles in the journals discussing Interpretation and Reports incorrectly.  Frequently, we see the report requirement documented only as Findings of the procedure (typically an imaging procedure).  Reports that only document Findings are incomplete and will not stand up to an audit.  The actual requirements are that the report must contain each of the following: Patient Information, the Diagnosis and the three reporting categories:

-  Clinical Findings
-  Change in Condition (Comparative Data)

-  Clinical Management. 


Furthermore, if the patient has more than one procedure performed there must be a complete and separate report for each procedure.


Compounding this problem is many EMR systems encourage doctors to use their reporting module, which in cases, is not compliant.  In some systems multiple procedures are grouped into a single report.  Other systems record only Clinical Findings in the Assessment section of the exam, making it impossible to produce a compliant report when requested. 


How costly is not doing an Interpretation and Reports?


We have see penalties and interest averaging between $40,000 and $60,000 per practitioner!  We have seen a solo practitioner hit with a $200,000 penalty for Interpretation and Reports!

EMR Cloning of Records


The other major subject of audits is for subsequent visit documentation of Chief Complaint, History and Review of Systems.  All the EMR systems provide a mechanism for a “One Click Bring Forward” for information to be brought from previous exams.  This is referred to as Cloning of Records.  The EMR vendors provide this option since EMR already adds time to an exam process.  Doctors like to use the feature as Cloning speeds up the process. 


“One Click Bring Forward” without proper review and updating of each individual element is non-compliant.  Auditors treat exams documented in this manner as non-compliant! 


In some cases, vendors use a single check box or button to indicate the doctor reviewed all the information pulled forward in the category.  Auditors consider this single check box action as insufficient as it does not demonstrate each item was separately addressed with the patient.  As a result, exams created in this manner are deemed not compliant and are denied.


In September Medicare published a document specifically calling this method of documentation non-compliant.  This means even with a defense of no notice can now only be applied to exams prior to September 2012! 


We have successfully defended several practices in appealing an audit by showing there was no notice prohibiting the “One Click Bring Forward” of records. 


The insurance companies know where the money is! 

They realize the shortcuts doctors are taking as they move to EMR systems.  Auditors have told us their companies realize they can obtain between $100,000 and $200,000 per solo practitioner through audits.  That is far more than they can realize through fee cuts. 


As a result, all the payers have significantly increased their audits.