MDNews - Greater Boston

C L I N I C A L D O C U M E N TAT I O N I S often in physicians' blind spots until an insurance audit leaves them in shock, with bank account balances significantly lower. The best way to insulate providers is through documentation training programs. In fact, a recent KLAS report identified training as the biggest concern for pro- viders. The report, "ICD-10 Perception: Can Technolog y Relieve Readiness Issues?", looked at the impact on provid- ers of the (then) impending deadline of ICD-10 and whether it was causing them to avoid certain processes such as readiness assessments. Though the focus of the study was on technology, KLAS researchers were surprised to discover that while technology was of moderate concern to providers, the larger concern was training. Based on my clients' visits to conduct documentation training for providers, I did not find this information surprising. These visits reinforced how valuable documenta- tion training services are — not only for solo physicians but also for group practices, which depend upon them to keep the eyes of the providers they employ focused on the business side of patient care. A perfect example of how valuable documentation training can be came in a one-off discussion with a hospitalist nurse practitioner following one of our training sessions. She pointed out that the training had made clear the need to provide daily updates to diagnoses and record billable procedures. The financial impact of this meeting was significant. The fact is, many providers fear insur- ance audits and are therefore too timid to report accurate levels of billing for which they can be reimbursed. They typically are misinformed or unsure of the documentation necessities for the patient history, physical exam or medical decision-making components. Providers require a succinct interpretation of the rules that pays attention to their specialty and service listing. Some practices choose to skip training and instead pay for audit insurance. In reality, audit insurance is more focused on improvement to avoid larger fines and frequently turns a blind eye toward the pro- vider's documentation. It is the face-to-face auditing and education that actually break physicians out of their routines and compel them to become compliant. Nothing wakes up a physician faster than speaking with an auditor and seeing in black and white what they have done wrong. It also strikes them when they understand what penalties they might incur for failing to document something as simple as a review of systems. As my compliance officer says, "If you did not document it, it did not happen." The other area where training is an invaluable resource for providers is in keeping up to date on compliance issues. Every year, the rules change, so docu- mentation training must be updated, as well. Many believe that EHRs can be helpful, but they, too, often end up out of date with their recommendations while waiting for version updates. In these situa- tions, it is always helpful, at minimum, to publish a yearly documentation handbook tailored to the specialty and services that are provided. When it comes to documentation, a little training can go a long way toward getting physicians and other providers the reimbursements to which they are entitled. Whether your practice bills at high levels to increase reimbursement or low levels to avoid insurance audit penalties, there is one simple answer to solve both scenarios. Billing accurately with documentation to back it up will maximize your reimburse- ment while avoiding the potential hit of a major insurance investigation. Timothy DiBona is the Business Director at Doctors' Management Service Inc. and President of Salus Resource Group. He has collaborated with hundreds of physi- cians over the past 25 years. He believes in trust-first relationships fueled by consistent communication. He can be reached at Tim@ DoctorsManagementService.org. ■ By Timothy DiBona Audit- Proof ++++++++++++++++ +++ + +++ + ++++++++++++++++ IT UPDATE M D N E W S . CO M ■ MD NEWS Greater Boston | 5

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