Proactively auditing charting in a medical practice is a crucial aspect of maintaining high-quality patient care, compliance with regulations, and overall practice efficiency.
A good baseline audit is always recommended for practices of all specialties to identify areas of risk. Our audit procedure includes a pre-audit meeting, the audit, findings report and a meeting with the practice principals. We review the findings and provide recommendations for the future health of the practice.
The audit may be a baseline of 10-20 chart notes per provider of various carriers. Depending on the findings, you may need to perform a more in-depth audit with quarterly, semi-annual or yearly audit to bring your practice into a compliant level.
When adding new graduates to your practice it is best to conduct an audit of their dictation to assure compliance and adequate reporting of billed services. This portion can also be included in their annual review to assure that they are documenting appropriately.
Should your practice be subject to a post payment audit or have documents requested by the carrier prior to payment on a claim it is best to have this request reviewed by your compliance officer. They should verify the accuracy of the documentation before it is released to the carrier. If you do not have a compliance officer on staff, bring in a consultant before documents are released to the carrier. If there is an issue with documented services your recommended corrective actions may assist you with any possible sanctions, recoupments, or future audits your practice may be subjected to in the future.
Here are some key reasons why medical practices should conduct regular chart audits: