Health insurance companies use audits to ensure clinical and billing requirements are met. Even if an ABA provider is taking all the necessary steps to ensure that they are compliant, a health insurance company may still trigger an audit to ensure no issues are found.
An audit may be stressful for an owner of an ABA practice, regardless of its size, but smaller practices may not have the resources to deal with the additional requests by auditors when one occurs.
This could result in potential consequences — prepayment review, contract termination, or reimbursement requirements to pay back paid claims that are deemed non-compliant — that can put a practice at risk. There’s even the possibility of a fraud investigation. If widespread problems exist, that could mean not only financial loss but also loss of business and reputation for the company.
As daunting as an audit and its consequences may seem, here’s what you need to know to make an audit as painless as possible:
What triggers an audit?
An ABA audit can happen for many reasons. Practices should prepare for these audits, as most will see them one or more times over the life of the business. Some of the common reasons an audit may occur include:
- Higher use of specific codes: If you use a particular code more often than expected — often in relation to peers — this could trigger an audit.
- Performing a higher frequency of service: In situations where you provide care more frequently to what your peers experience, that could also trigger an audit.
- Previous problems, violations, or errors: If you have experienced claims denials in the past or a fraud claim, that could mean more frequent audits.
- Complaints from patients: If a patient feels that you have incorrectly filed a claim or had another issue with your service, they may lodge a complaint with their health insurance provider.
- Random review: Health insurance companies will perform random audits to ensure that all companies, even those without any claims issues in the past, are confirmed to be compliant.
- ABA codes are permanent category 1 CPT codes: With the change to category 1 CPT codes, audits are more likely to occur.
Best practices to prepare for an ABA audit
Preparing for an audit long before one is requested is the best strategy. That means taking steps to proactively maximize the amount of information or data available to support your claims. Some key strategies to help minimize audit risks include:
- Do your research before you get audited: While you may think you are fully compliant and will never get audited, the reality is that even companies that are perfectly compliant will get audited from time to time. Ensure you understand how the audit process works and reach out to others to learn about their experiences so that you’re better prepared.
- Standardization: Consistency is critical for health insurance companies. Ensure you are using standard protocols and templates in all evaluation processes. That way, there will be accurate, consistent documents to prove care needs. Showing medical necessity is a critical concept that auditors nearly always need to verify.
- Minimize irregularities in billing: One key to getting through an audit is providing accurate, organized information that clearly supports claims. Billing consistency is critical to ensure proper payment calculations.
- Expertise in billing: ABA billing expertise is important, as this is one of the most common concerns in audits. Having a process in place to minimize errors and using a service capable of ensuring clear documentation and practice management could help minimize audit risks.
- Practice: Staging mock audits is an excellent way to find problems and fix them before they occur. Mock audits can be eye-opening, especially when conducted by an experienced provider, pinpointing common areas of concern and hidden problems you may not know exist.
- Accuracy across the board: From improper use of billing codes to questionable diagnoses, you must provide accuracy and consistency across all areas of the practice. This includes avoiding HIPAA violations, ensuring no claims errors occur, and maintaining clear, standard fee schedules.
- Document storage: Proper record storage can save you a lot of headaches down the road. While HIPAA rules must be in place, you should make sure that your records are comprehensive, locked, and hidden from anyone not on a patient’s care team.
Managing audits is key to long-term success. Without a plan in place, ABA practices may find it nearly impossible to get through these trying audits.
Missing Piece specializes in the services you need
Fortunately, Missing Piece offers the support you need to manage an audit with ease. By providing full ABA billing services, our ABA billing solution will ensure all your documentation is consistent and within compliance requirements. Our range of services also includes ABA compliance audit support, so if you experience an audit, you don’t have to go through it alone.
Contact Missing Piece today to learn more about ABA audits and to get the support you need to ensure a smooth audit.