02/20/2002    Michael M. Rosenblatt, DPM

Are You an "Audit" Target?

RE: Are you an "Audit" Target?
From: Michael M. Rosenblatt, DPM

Recently I assisted a podiatrist (who keeps
excellent treatment records) on an HMO audit. It
was actually a "pleasure" to work with this
doctor because the record keeping allowed us to
aggressively contest the audit.

By now, most of us know that all podiatrists who
go to nursing homes are Medicare audit targets.
This also applies to those podiatrists who "work"
for businesses that supply podiatry services to
nursing homes. Most employed podiatrists don't
realize that they PERSONALLY are an audit target
for the billing policies of their employers. If
Medicare thinks that those "corporate" billing
policies are improper or incorrect, BOTH the
business owner and the employee are subject to
the same audit risks and penalties. Employed
podiatrists MUST make it their business to know
how billings are being done in their name.
Ignorance is not an excuse and Medicare will not
consider your "lack of knowledge" as a mitigating
factor.

SHOULD YOU CONTEST AUDITS?

Some insurance companies and HMO's provide
finder's fees for their auditors. Of course they
will deny it absolutely. Although I am not a
lawyer, it is my impression that there is nothing
illegal about paying finder's fees to auditors.

Another question is: "Do other insurance's find
out about audits against you?" If you suppose
that audits against you are "private," you may be
wrong. I don't believe that there are any
contractual obligations to keep the results of
your audit private between you and the auditors
or the insurance company they represent. This
means that if you DON'T contest an audit
aggressively, other insurances may find out about
that and consider you a good target for getting
money back.

There are no firm data on what percentage of
doctors fight their audits, especially
for "private" insurances. It is my impression
that only a small number do, say between 10 and
20 percent. However I have no scientific basis or
data on which to base that. This would have had
important implications for the audit I helped on.
The auditors made some absolutely stunning
mistakes!
Had we not contested the audit, we would never
have discovered them.

The most difficult time in dealing with an audit
is the first day you receive the demand for money
and the auditors' report against you. I'd
recommend that you NOT deal with it the first
day. Allow yourself a period of "psychological
mourning."

In my experiences with audits, reading through
the demands makes you frightened, angry and
depressed. The only way to deal with that is to
start aggressively dealing with each claim made
against you.

It is my happy news to point out that once you
get started on the "project" it becomes easier
and easier to contest their demands based upon
the CRVS and your chart notes. This is because
audits are rarely conducted by other podiatrists.
Often times they don't really hit on your
most "vulnerable" areas. You just need to get
past the first "few hours" of effort. Those are
the most psychologically difficult. Don't think
like the auditors. Look for every feature
possible to defend your billing positions,
including OTHER chart notes on different days you
saw the patient--to buoy your arguments.

Include as many defending documents as you can,
including copies of other chart notes and the
CRVS books. Add up their money demand. Many times
they add incorrectly. If you chose to hire a
lawyer to help defend you, I'd strongly recommend
a podiatrist-lawyer, since non-podiatrist lawyers
really don't think like you. Send your contesting
report back ON TIME. It is best to use a legal
message service. Legal message services will
require an identical copy to have the insurance
company verify. The message service will return
that identical copy back to you with the
representative of the insurance company signing
that they are the same. This is an adversarial
process. Make NO statements to any representative
of the company in person or on the phone.

You really need help with audits. A fresh point
of view is very important. Often another
podiatrist can see things that you completely
miss. Ideally it should be somebody who has
successfully faced audits themselves, or have
represented insurance companies.

Most important: fight your audits aggressively.
The word will "get out" that you are not an easy
audit target. That is one of the best ways to
protect your reputation. You don't want other
insurances to think that you are "easy."

Michael M. Rosenblatt, DPM
San Jose, CA
ROSEY1@prodigy.net

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