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Audit Triggers to Avoid


Being proactive is the most important way to prevent an audit or mitigate the potential penalties if you are audited. Take the time to review procedures and records to identify potential audit triggers.

Audits of coding, payments and compliance with a myriad of policies and regulations are now a permanent process in the health care arena. Following the success of the Recovery Audit Contractor (RAC) projects, the alphabet soup continues to add more letters. We have added MAC, MIC, QIC, ZPIC, OIG, DOJ and HIPAA audits, just to name a few. You should take the time to review your procedures and records to identify potential triggers.

Falling off the bell curve

In this age of technology, the use of statistics and data mining are commonplace. The Centers for Medicare and Medicaid’s bell curve has been used for years to identify instances of over-coding (and under-coding) Medicare claims.

Beware of billing all Evaluation and Management visits at the same level. Your practice may be centered on a code of 99213, but you will certainly have claims that don’t quite meet all the E&M standards, or claims where you should document a little more information, or review one more system to meet the next higher level.

Be aware of variations from the norm and changes in coding practices. Most often, your practice management system will give you this information to review your practice patterns.

High utilization of modifiers

Modifiers were developed to identify those situations that are outliers to the normal procedure and coding of claims. The overuse or misuse of modifiers can cause delays in processing your claims and can trigger payer audits. Overuse of modifiers -25 and -59 has been an instant red flag to payers. Make sure your coding and billing personnel are trained to use modifiers properly and understand their purpose.

Cloned documentation

Electronic Health Record (EHR) systems and templates have encouraged the use of “cut and paste” shortcuts resulting in cloned documentation. Make sure that you have actually reflected the patient’s chief complaint and performed all the services for the specific patient, including individualized notes and data to support the medical necessity of the visit, or procedure. Remember that the templates in most EHR systems are created to prompt for documentation and not intended to produce the note.

Disgruntled employees

At one time, a disgruntled employee might call the Internal Revenue Service or Department of Labor and cause some grief. Today, the options to make your life miserable seem endless, and they can be triggered with a single phone call.

Make sure your employees have the data they need to perform their job and an outlet for any complaints. Communication is the key. Be aware of signs that an employee is about to go bad, and keep good personnel records documenting any breach of policy.

Patient complaints

Payers provide hotline numbers to encourage patients to call if they believe they were billed for a service not received or that they were somehow treated unfairly. Make sure that you provide the first outlet for the patient to ask questions or obtain information and encourage the patient to use it. Respond in a timely manner. Most often you can give the patient a satisfactory answer to their problem or question and they will be happy.

As patient satisfaction measures become more important to reimbursement, this outlet will not only alleviate an audit trigger, but will provide you with the maximum payment possible.

Compliance plans

Not so long ago, practices scurried around to put all sorts of compliance manuals together. It’s time to blow the dust off of those binders, and actually review and use them. Design your own tests of compliance and document the results, including any policy changes that may be necessary. If you are audited, you may mitigate the potential penalties by proving the policies are in place and are being used.

In addition, make sure your staff is aware of the 60-day repayment rule for Medicare overpayments, and that a procedure is in place to identify and return these payments to the Medicare intermediary. Failure to do so may trigger penalties under the False Claims Act.


Health care providers will continue to face intense scrutiny, not only by governmental payers and enforcement contractors, but also by other third-party payers as they follow suit.

Noncompliance can result in the potential loss of licensure, recoupment of payments and/or penalties under the False Claims Act. Remember that most of the contractors are paid based on what they recoup from you, so avoid triggering the audit in the first place.

Being proactive is the most important way to prevent an audit or mitigate the potential penalties if you are audited.

Beverly A. Miller, CPA, CAPPM is Manager of Physician Services with Hayflich Grigoraci, PLLC in Huntington, WV. She is currently the President of the National CPA Health Care Advisors Association (HCAA).

Hayflich Grigoraci, PLLC is also a proud member of the National CPA Health Care Advisors Association (HCAA). HCAA is a nationwide network of CPA firms devoted to serving the health care industry. Members provide proactive solutions to the accounting needs of physicians and physician groups. For more information contact HCAA at info@HCAA.com.

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