Internal Auditing Best Practices

August 22, 2016

5 steps to increase preparation in a private behavioral health practice.

Audits are a nominal part of worklife for publicly funded behavioral healthcare organizations, but even small private practices are subjected to them from time to time. Some private practices get anxious at the thought of an audit. Others feel confident. The difference between the two groups is that the latter has assessed its risk of failure (and chance at success) in advance and on a regular basis.

Adequate preparation comes from conducting internal audits regularly. The following is a list of important steps to take to ensure your practice’s audits are meaningful and useful when the time comes.

1. Select charts carefully and don’t review your own charts
Sampling methods may vary depending on the caseload of the practice, but a general rule of thumb is to ask a staff member to pull a client list for a one-week period then select every fifth record until there are ten total. Analyzing records from a specified period of time will be reflective of any trends in the data, as opposed to pulling records blindly at random. The reviewer must have strong knowledge of coding rules, auditing worksheets, and healthcare terminology.

2. Use the same rules as auditors
Auditors might interpret guidelines in different ways, but they usually adhere to a few simple rules. For instance, auditors are supposed to use whichever evaluation and management documentation guidelines that are more beneficial to the provider when auditing, be they the 1995 or 1997 guidelines. Identifying which circumstances apply to the practice and proceeding accordingly will eliminate surprises.

3. Keep coding audit results educational
Take the opportunity to review and study the results of coding audits and discuss what can be improved. Improvement happens naturally when everyone on the staff is committed to the goal of complying with documentation guidelines in order to avoid an adverse impact on the practice. Also, avoid heavy-handed responses to chart audit results. Treating audits as a chance to punish staff will create defensive behavior that can harm the practice even more than a simple miscoding.

4. Work at correcting errors
An internal audit might uncover instances of over-coding, under-coding, or discrepancies between billing codes and the actual services rendered. Conducting an internal audit accomplishes very little unless the practice follows through with remedies for the problems identified. Establish an on-going reporting and feedback system and record error rates and trends in documentation.

5. Use your EHR to your advantage
There are usually several ways an EHR can help prepare for and conduct an internal audit. Practices that have an EHR system in place can enjoy the following perks:

  • Consistent organization of charts
  • No issues resulting from handwriting illegibility
  • Records are centrally located, even for practices with multiple locations
  • Mobile access for internal and external auditors saves money
  • Formatted templates help ensure compliance with local, state, and federal regulations
  • Notification functionality so errors can be corrected prior to claim submission
  • 24-hour access

Practices that have a clear understanding of how well they would fare against an external audit in advance will be more prepared for when that day actually comes. Audits will always be disruptive to a certain degree, but making the right preparations will mean the difference between a mild annoyance and a major setback in practice productivity.

Interested in seeing how a robust EHR can help prepare your practice for an audit? Click the button below to learn more!

Last Updated: March 29, 2017