When the Audit Bell Rings: Navigating Your Mental Health Practice Through an Insurance Audit and Building an Effective Audit Team

Getting audited by an insurance company can instill fear and anxiety in the hearts of even the most seasoned mental health practitioners. While these audits can be nerve-wracking, they're often just a standard procedure for insurance companies to verify that billing and treatment align with their regulations. Ignoring the possibility of an audit isn't a viable strategy. Instead, proactive preparation and a competent audit team can help you endure the process and emerge from it more robust and efficient. This blog post aims to guide you through the immediate steps to take upon receiving an audit notice and how to form a strong audit team.

Why Audits Happen

Regulatory Compliance

Insurance companies conduct audits to ensure your practice complies with their rules and regulations. Compliance extends beyond just correct billing; it also means verifying that the treatments provided are medically necessary and adequately documented.

Fraud Detection

Audits also serve as a fraud detection mechanism. While no practitioner likes to think that they could be suspected of fraud, insurance companies have a responsibility to stakeholders to monitor for irregular billing patterns or treatment protocols.

Routine Checks

Sometimes, audits occur as part of a routine procedure. Just like your car needs an occasional check-up, insurance companies periodically assess your practice's financial and medical aspects. These routine audits help insurers maintain a standard quality level across their network.

The Immediate Steps

Don't Panic and Prepare

The initial emotion is often panic. However, remember that audits often serve as routine checks. Take a deep breath, and put your initial focus on gathering the necessary team and documents. Panic can cloud judgment and delay the preparation process.

Collect and Organize Documentation

Your practice should already be maintaining comprehensive and up-to-date patient records. The audit notification will typically list the specific files and documentation needed. Double-check these documents for accuracy, as these will form the backbone of your audit. Review patient files, billing records, treatment plans, and other documentation requested. Properly organizing this information beforehand saves time and stress later.

Building Your Audit Team

Choose a Qualified Team Leader

Appoint a team leader who knows the ropes and can act as the point of contact between the practice and the auditor. This person should be organized, familiar with the practice, and preferably experienced with insurance audits. The leader oversees the document collection, maintains a timeline, and ensures team members perform their tasks efficiently.

Include Your Legal Counsel

Insurance audits can have legal ramifications. Legal guidance is crucial for interpreting state laws, ethical guidelines, and contract terms that apply to your practice. Getting an attorney involved helps avoid legal pitfalls during the audit.

Utilize Billing and Coding Specialists

Any errors in coding and billing can turn an otherwise smooth audit into a nightmare. Your billing and coding specialists will help ensure your invoices match your services. Their involvement can be the difference between an audit that concludes quickly or one that drags on for months.

Involve Clinical Staff

A clinician, perhaps a senior therapist or psychiatrist, should be part of the audit team. This professional can provide the necessary clinical context for treatment decisions, which can be pivotal in justifying certain billings or treatment protocols.

The Audit Process

Conduct a Pre-Audit Team Meeting

Before the audit commences, hold a comprehensive meeting with your team. Lay out the timeline, discuss the scope of the audit, and assign roles and responsibilities. A well-organized meeting sets the tone for the audit and clarifies everyone's role.

Establish Clear Communication Channels

The team leader should act as the exclusive liaison between your practice and the auditor. Consistent communication is essential to avoid misinterpretation of requests or findings. All inquiries and submissions of additional documents should pass through the team leader.

Engage in a Post-Audit Assessment

Once the audit concludes, convene another team meeting to assess the outcomes. If the auditor has noted discrepancies or areas for improvement, this is the time to develop an action plan. Legal counsel can interpret the implications, and the clinical staff can suggest quality improvement methods.

Final Thoughts

The prospect of an audit by an insurance company can be unsettling, but it doesn't have to be a crisis. A well-prepared practice and a robust audit team can make the difference between an audit that's a disaster and one that becomes an opportunity for improvement. Audit experiences offer a chance for valuable insights into the operational aspects of your practice, helping you refine procedures and maintain compliance.

So when the audit bell rings, don't view it as a death knell. See it as a wake-up call—a call to action that mobilizes your team, streamlines your operations, and ultimately makes your practice more robust and resilient in the long run.