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Forming a Plan for the Dreaded, Inevitable Audit

While they can be unpleasant, audits are a fact of life in a wound clinic. This author provides a guide to starting an audit oversight plan, how to handle additional documentation requests and how to submit complete documentation so your audit receives favorable results.

Through previously published audit-related articles in Today’s Wound Clinic, we have reviewed how to successfully navigate through today’s world of audits and we also reviewed how to prepare the best, most comprehensive reply to an audit as well as managing and monitoring all audit activity.  

In this article, we’ll review the day-to-day interaction with audits that everyone must contend with on a regular and sometimes daily basis.  

We know that audits of all types happen with a great degree of regularity for hospitals, both for inpatient and outpatient procedures, and for providers. Having an audit oversight plan or process is, or at least should be, part of the overall policies and procedures established for any hospital outpatient department or a provider’s private practice. The audit oversight plan should be clear and specific with defined processes to be followed, in order to be truly successful in today’s health care industry. Staff must know how to identify and quickly react to all audit activity.

The audit oversight plan or policy should be incorporated into any desk procedures, guidelines or manuals that the staff is meant to review and follow throughout the course of their daily task and responsibilities. All too often we hear of unfavorable audit findings because an additional documentation request (ADR) sat on someone’s desk unanswered. All should be aware of audit related communications, who they may come from, and how they are meant to be handled. This would include knowing to whom ADRs should be sent for processing and/or how to properly respond.  

Formulating an Audit Oversight Plan

To begin, most, if not all, audits will start with an ADR. In instances when documentation requests are made verbally or by phone, a valid written request should be insisted upon or required before releasing any documentation. An audit response team could be a specific department or designated key personnel. They should be identified in the audit oversight plan and known to all within an organization, hospital or medical practice. This is an important first step, particularly in large hospital systems where individual departments or practices are located at the same address. ADRs sent to the radiology department, for example, may need to be quickly routed to particular staff in the health information management (HIM) department. Front desk or receptionist staff should know exactly where to route such request when they are received.

Many hospitals and medical practices now have established audit response teams that are often housed within the Revenue Cycle, Revenue Integrity or Compliance departments. Educating all existing staff as well as new staff going through the on-boarding process should be a priority for all hospitals and medical practices. Some hospital organizations may also have this type of information now included in their general employee handbook.

All should be aware of audit related communications, who they may come from, and how they are meant to be handled. Properly Handling ADRs  

Contained within any audit oversight plan, one could expect to find detailed information for timely and proper handling of all ADRs. Keeping in mind the usual 45-day time period for responding to ADRs, it’s imperative that the audit plan address the swift and efficient need for getting the request to the right team or designated personnel as soon as possible. Remember that in most cases, the 45-day response requirement begins with the date of the letter, not necessarily the date the letter lands in your department or the date it finally gets to the proper staff for processing. The clock starts ticking with the date of the letter and considering mail time, then routing time within a hospital, it’s not uncommon to be a week or more into the 45-day timeframe for responding when the ADR actually reaches the correct destination for processing.

Once the ADR reaches the designated team for processing, it is recommended that all documentation requests be logged or entered into a tracking or monitoring system. In an effort to support a timely reply, the date received and the date the response is sent should be recorded. The reply method should also be noted. Most ADRs will include information regarding the options or methods for responding. Many payers, including CMS’s Medicare Administrative Contractors (MAC) now have secure portals that may be used for submitting documentation. Of course, faxing and mailing paper copies are also still viable options. Remember that when mailing medical record documentation, be sure to send it secure and certified with tracking on the package.   

Regardless of the method used for replying, be sure to keep copies, either electronic or paper, of the documentation being submitted and the date the reply was submitted.  Several colleagues have noted that faxing is still their preferred method as it does provide confirmation of the transmission and eliminates the need for an extra copy. Hospital policy regarding ADRs and the preferred documentation reply method should be included in the audit oversight plan and strictly adhered to.

Responding in a timely manner is incredibly important. Documentation request not responded to timely or not at all will likely result in a denial on a prepay audit or generate a recoupment on a previously processed claim. CMS frequently reports that no reply or an insufficient reply are routinely listed as some of the top denial reasons throughout all of their audit activity and programs.

Submitting a Complete and Supportive Documentation Reply  

Experienced ADR reply teams are well aware of the importance of submitting a complete reply. All ADRs will identify the payer or entity requesting the documentation and a general reason for the request. As you would expect, they will also include the specific patient details such the name, policy or claim related details as well as the date(s) of service to be reviewed. Most ADRs will also include a specific list of documentation elements or components that are needed for the review.

For example, an ADR for debridement services could include a specific request for the wound assessment, measurements both pre- and post-debridement, photographs, the plan of care as well as details to the wound healing progress or factors that may be complicating or prohibiting wound healing. Hyperbaric oxygen therapy (HBOT) documentation requests have been known to include a list of a dozen or more specific documentation components and often include a request for the superbill or itemized billing statement.

The moral of the story is to be sure the entire list of requested documentation items is satisfied before submitting the documentation reply. It’s recommended that when possible, another staff member review the documentation packet as compared to the list of requested documentation before it’s actually submitted. Remember to organize your documentation reply packet in the most logical order so that another clinical reviewer clearly understands the course of treatment, what services were rendered, and that they are completely supported. Numbering your pages is also suggested as this could be helpful when discussing the audit findings with the auditor. If unfavorable findings are noted, be sure to properly request whatever educational opportunities or post-audit review is available. There are a number of instances when auditors may accept further clarification or additional documentation when there are initially unfavorable findings. Be sure the audit oversight team is taking advantage of those opportunities.

Tips for Ensuring Audit Success

Having a solid plan for handling all ADRs not only ensures audit success, it also helps to stabilize the value of your reimbursement dollars. Without clear direction or a plan for processing ADRs, we run the risk of time-consuming and unnecessary denials. We also know the more staff time that is involved in addressing denials and then navigating the appeals process only lessens the value of your reimbursement dollars. An ADR oversight plan or process can help to avoid unnecessary denials particularly in a prepay review.

Unfortunately, we do seem to have to fight harder and smarter to maintain the integrity of our current reimbursement dollars. Submitting a complete and timely reply will certainly help to avoid those unnecessary denials and the overly burdensome appeals process. We also know and appreciate that ADR-related statistics and data are now part of many revenue integrity and compliance programs’ key metrics and benchmarks. Additional documentation request from any payer but particularly from Medicare, can lead to further revenue-related concerns if not handled properly and expeditiously.  


Without a doubt, audits are now a common if not daily routine process. They can easily and quickly have a negative revenue impact your department or practice if not handled correctly and efficiently. With a clear and concise audit oversight plan, a prompt and complete reply can be appreciated, which is the first step in the process to receiving favorable audit results. Be sure to establish a clear and concise process. Designate or assign the appropriate staff to process all documentation request, including the submission and subsequent monitoring of every request. Lastly, be proactive in keeping up with updates from all of your payers, especially your MACs. The MACs routinely publish updates through their electronic list serve updates and can provide valuable and timely information.  

Before concluding this article and perhaps leaving our reader confused about the need to have an audit oversight team in place, it is important to acknowledge that as of this writing, CMS still has not restarted its Targeted Probe and Educate (TPE) audit program. However, CMS has resumed other audit activity including Recovery Audit Contractor (RAC), Supplemental Medical Review Contractor (SMRC), and Unified Program Integrity Contractor (UPIC) audits. MACs have also resumed their medical review related audits and probes. In conjunction with establishing your ADR oversight plan, also remember to check your MAC’s Med Rev page on its website for a listing of the items and services that are currently under review.

For those instances when a hospital or provider or audit oversight team member becomes engaged in any of the current audit processes, be sure to communicate with the correct contractor. For a list of the various CMS contractors for each state, please use this link for the interactive Review Contractor Directory.

Establishing this plan and approach will help to further ensure success and favorable findings through the ADR and subsequent audit process.  

Good luck and best wishes for a success ADR Oversight Program and successful audit process.

Diane G. Weiss, CPC, CPB, CHRI, is the Vice President of Revenue Integrity & Education at RestorixHealth.

Diane Weiss, CPC, CPB, CHRI
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