Insurance Audits - Reality
   - One of the costliest issues facing all medical practices is an insurance audit.
   - Insurance auditors tell us more than 90% of practices will fail an audit!
   - Typical penalties are between $150,000 to $225,000!  Many are much higher.
   - Practices are completely unprepared for an insurance audit.
   - Most EHR systems are not compliant. The auditors know this and use this in their audit.

What are My Risks in an Insurance Audit?
   - All payers have significantly increased their auditors and audits.
   - Your chances of being audited constantly increase!

   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! 
     - 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!
            We heard from auditors confirming the failure rate because of the pre-selection.
     - Auditors apply the high failure rate to all reimbursement paid to your over multiple years. 
            This is referred to as "Extrapolation".  Interest and penalties are then added.
      
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 for auditors to find is the recording of Chief Complaint, Patient History, Medications and ROS
          Most technicians simply pull forward from previous. 
          There are specific rules for information pulled forward.  Most technicians are not familiar with these rules.
          This results in auditors classifying the records as "Cloning" and are denied.
     - Most EHR systems exam verification is not correct.  Auditors typically find these "verified" exams non-compliant
         

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!