What are your chances of being audited

       What will failing an Audit Cost You?   




Nteon Practice Consultants

    Performs Preventative Practice audits to help you avoid failing a costly audit.

    Conducts appeals for practices that failed an insurance audit.

We have extensive experience in audits.

What are My Risks in an Insurance Audit
    - All payers have significantly increased their auditors and number of audits.  Increasing your chances of being audited.

 - Many audits are random.  Some are based on a review of past claims and reimbursement.

 - It is important to note, most EHR systems are not compliant. The auditors know this and use this in their audit.

 What is the Insurance Audit Process
     - Once a practice is selected and prior to the audit, auditors review your previously submitted claims looking for issues.  
     - They select a set of patients based on those claims they think will fail!  Between, 40 – 100 patients. 
     - This is never a random selection.  The auditors want to make sure the records selected will result in denials.
            We refer to this as "Cherry Picking" 
     - Because they pre-select , this typically results in a failure rate over 90%.
            In all the audits we have been asked to appeal, we have never seen less than 90% failure of records reviewed!
            Because of the pre-selection, we also heard from auditors, they fail over 90% of practices audited!
     - The auditors apply the failure rate (typically 90%) to all the reimbursement paid to you over multiple years.
                This is referred to as “Extrapolation”.  The auditors then add Interest and Penalties to that amount.

This is an actual audit finding showing penalty calculation.  Extrapolation:
                                                 Records Reviewed     45 
                                                 Records Failed           41    
                                                 % of Records Failed   91%   (Typical)
                                                 Total Reimbursement  2010 – 2015  $127,569    (Only $17,000 was identified.  Rest is Extrapolation.)
                                                 Failed % of Total Reimbursement     $116,087
                                                 Interest and Penalties                          $79,695
                                                 Total Due by Practice                        $195,782    
What do the auditors find
     - One of the  easiest things to find is the recording of Chief Complaint, Patient History, Medications and ROS
          Chief Complaint - most techs enter "eye exam" or "referred by" or other phrase.  The auditors always deny the exam! 
          History, Medications and ROS - most technicians simply pull forward from previous.  This is "Cloning" and is denied
     - Even though EHR systems have exam verification, unfortunately the auditors find these "verified" exams non-compliant
          The most common exam type for medical exams, is not documented properly in most EHR systems.

          Frequently the auditors find these "verified" exams completely missing required components of compliant exams.

Practices that failed an insurance audit.  
    Unfortunately, we actually spend more time helping practices that failed an insurance audit!
    This is only a few of the cases of failed audits we are currently or previously worked on appeals.

     Practice Size          Penalty
       Two doctor                    $1,500,000  
       One doctor                       $650,000

      Two doctor                    $1,090,000  
       One doctor                       $195,000
      One doctor                       $270,000
      One doctor                       $210,000
      One doctor                         $75,000
      One doctor                       $156,000
      One doctor                       $220,000
      One doctor                       $195,000

    Every week we hear from multiple practices that asked for help because they failed an insurance audit!
    You need to protect your practice!



Call Toll Free:  888-866-5367
Email us:  info@NteonConsultants.com