Behavior Analysis is becoming an increasingly respected field worldwide. Its growing popularity has even prompted big changes in the American healthcare system. Nevertheless, this newfound recognition comes with great responsibility. Any BCBA working with insurance companies will likely experience some form of auditing.
“If you haven’t been picked, you will.”
The question isn’t “if”; the question is “when.”
Auditing and jury duty have a lot in common; if you haven’t been picked yet, you will. Chances are, it’ll be the furthest thing from your mind. Then one day out of the blue a letter, email, or phone call will surface and you need to be audit-ready.
Understanding Auditing
From insurance companies to municipalities, most payer types have strict policies limiting benefit coverage. Submitted claims deemed non-compliant can prompt denial or revocation of payments, even if sent months ago.
The impact of an audit can vary from a minor inconvenience to a major disruption.Larger companies with robust technology may be equipped to handle audits, but the stakes are much higher for smaller practices. Limited manpower plus subpar technology is an auditing recipe for disaster.
How to Prepare
Any company can encounter an audit, but certain “red flags” make it happen more frequently. While some risks are hard to eradicate completely, the biggest risks can be fixed and make you audit-ready.
- Risk: Lack of Standardization
Insurance companies love consistency, especially when it comes to assessments and treatments. If your practice doesn’t adhere to standard protocols and templates, your clinical evaluations become prone to questioning.
Solution: Standardized Templates
CentralReach’s customizable forms with drop down menus make it easy to implement protocols and checklists for quality control. These templates help verify your decisions and deter payers from second-guessing them. - Risk: Billing Irregularities
Payers also love to see billing consistency, so fluctuating rates attract scrutiny.
Solution: Standard Fee Schedules
CentralReach’s fee schedules illustrate billing consistency and clearly calculate payments. - Risk: Outdated Staff Credentials
When payers and states change certification requirements, providers are expected to adapt to them. Continuing to practice with outdated credentials can prompt denying or revoking payments.
Solution: CentralReach Marketplace
CentralReach’s web-based Marketplace supports the exchange and verification of training materials. This makes continuing education accessible and convenient with this online portal. - Risk: Faulty Billing Codes & Questionable Diagnoses
Human error occurs in any industry, but some mistakes look suspicious to insurance companies.
Solution: Integrated Practice Management Software
When scheduling, authorizations and claims link to Clinical Notes templates, careless mistakes are easy to eliminate. - Risk: Deviation from Industry Averages
Any outlier from industry norms becomes vulnerable to payer scrutiny. For example, if you’re billing 50 hours a week, and BCBAs usually work 30, payers may ask for validation.
Solution: Standardized Templates with Progress Reports
When reports clearly illustrate client progress, they can verify deviations from the average. - Risk: Obvious (and Less Obvious) HIPAA Violations
From loose papers to crashing hard drives, HIPAA violations are expensive mistakes that will quickly prompt an investigation. Even less obvious offenses (including non-encrypted video calls) can become an auditing magnet.
Solution: HIPAA-Compliant Document Management
From sophisticated hackers to natural disasters, protecting information is a major responsibility. Having CentralReach equip you with a HIPAA-compliant system is a stress-free, efficient solution. - Risk: Claim Errors
Claims with incorrect billing and client information will eventually appear on an auditor’s radar. Combing for errors can be time-consuming, unless you’re using software.
Solution: Ask for Help
When your practice has the right partners involved, you can transform vulnerabilities into bulletproof audit-readiness: - Talk to your Clearinghouse: They will point out claim risks, but only if you ask!
- Contact CentralReach: Our Claims Manager module has quality control filters that scrub claims prior to submission. Our support team can show you how.
- Join our Webinar: Knowledge equals power! To learn what you can do, join our webinar on August 28th, 2015 at noon EST.
Co-Authored by Dr. Michael Cameron, and Christie Calahan, CentralReach’s Director of Marketing and Communication.
About Michael Cameron:
Michael J. Cameron, PhD, BCBA-D
Chief Scientific Officer, ObiGobi Solutions
