Investing early in practice-management software can prevent arduous audits.

Imagine you have just been given news that your practice has been selected for an audit. When the initial chills finish running down your spine, will you start plotting your escape to another country? Or will you find comfort in knowing that your records are compliant, consistent, and organized? All practitioners would prefer to imagine themselves in the latter situation. But if you’re reading this scenario and you still can’t stop trembling, there are things you can do to secure your chances of not only surviving an audit—but not being audited at all.

According to health care professionals, pristine medical records are the best way to avoid an audit. If you are selected, neat, organized records will keep auditors happy and less likely to prolong the process with painstaking attention to detail.

One of the best ways to keep your records in order is to implement an electronic medical records (EMR) system. These days, software companies offer multiple features that will help you through an audit and facilitate the operation of your practice—an attribute that is sure to keep you whistling while you work.

Here to offer advice on EMR and how to handle an audit are some experts from the burgeoning field of practice-management software: David McMullan, vice president of product management for Source Medical Solutions Inc, Birmingham, Ala; Steven Petrie, CEO of SpectraSoft, Tempe, Ariz; Gerry Stone, PT, MEd, GCS, founder and president of ReDoc Software, Nashville, Tenn; and Stephen Welty, director of sales and marketing at Raintree Systems Inc, Vista, Calif.

How does adopting EMR help a practitioner avoid an audit?

McMullan: An EMR system helps the practitioner with both compliance and overall risk mitigation by ensuring consistency of documentation throughout the care of each patient. An EMR system also incorporates powerful business logic, giving the practitioner the ability to provide real-time access to all regulatory changes for the physical therapy provider. Finally, the accuracy and legibility documentation in an EMR proves to be a strong deterrent for an audit.

Petrie: A good physical therapy documentation system will produce documentation that is comprehensive and consistent. Ideally, it will have templates organized by body area of treatment with all the observations and tests logically organized. The system should be designed to facilitate compliance with Medicare and other federal-specific and state-specific documentation requirements. The system should also automatically capture charges from the documentation so that the charges and documentation always match. Comprehensive, consistent documentation that always agrees with the billing will reduce the number of audits when the payors see the quality of documentation.

Stone: Having compliance along with comprehensive, consistent, and legible documentation that reflects the latest clinical standards of practice is the best way to avoid or get through any audit.

Welty: When EMR are completed with the right methods, they can pass the muster of payors who are looking for redundant clinical documentation. Payors are looking for patterns of documentation that point to batch-documentation processes.

What are the worst forms of audit?

McMullan: The worst forms of audit are the ones you are not prepared for! The best approach is a proactive one; expect an audit, and implement the processes and information systems into the normal business practice for each practitioner.

Petrie: No one thinks any type of audit is a favorite recreational activity. But when documentation is incomplete, illegible, or missing, an audit is a nightmare. A good documentation system, properly implemented, will let you face an audit with a smile instead of worry and fear. I think a practice’s worst nightmare would be to have the Office of Inspector General (OIG) pay a visit. Many private insurance contracts or Insurance and Pensions Authority memberships are dependent on having a Medicare provider number. So not only are there steep fines if a problem is found, it could impact all of the other business lines for a clinic.

Stone: The worst is an audit by the OIG and/or the Federal Bureau of Investigation, who have reason to believe that fraud and abuse of the Medicare program has occurred. The second worst is a “100% medical review” of all documentation. Unfortunately, many of our customers learned the hard way and waited until after an audit to purchase software.

Is there anything a practitioner should do to fortify his/her practice in the event of an audit?

McMullan: The first thing to do is to complete a formal assessment prior to the audit and identify any and all areas that need to be addressed. Second, create very specific action plans to rectify all areas of weakness and include timelines for completion. Finally, prepare all necessary documentation and logs for the auditor in advance. The more difficult you make it for the auditor to get access to information they need, the longer and worse the audit will go for the practitioner and their practice.

Petrie: If you are taking steps to fortify your practice in the event of an audit, it is really too late. I think practitioners should have a mind-set to set up policies, procedures, and systems that fortify their practice against the eventuality of an audit. A good EMR system will help by supporting not only billing, but the medical necessity of the services provided and meeting the documentation standards of Medicare, the Health Insurance Portability and Accessibility Act, and other federal and state regulations.

Welty: Practitioners should complete self-audits and have at least one outside entity complete random audits on a regular basis.

If a practitioner is summoned for a Medicare audit, is there anything that the practitioner should not do?

Petrie: Don’t be unprepared (and don’t run for the border)! Seriously, if your documentation, records, and internal controls are in place and current, you have little to fear. The time to prepare for the audit is now, not when you are summoned for the audit. Self-audits and self-auditing documentation systems are critically important.

Stone: Do not try to go back and fix the documentation. Do not try to hide or mislead anyone. However, seek legal advice before saying too much.

Welty: Providers should not simply hand over access of their clinical tracking application without familiarizing the investigating entity with the application interface. The last thing you want to do is make the audit difficult for the individuals involved.

What are some exciting breakthroughs in EMR software?

McMullan: The most exciting technology advances in EMR software are Web services, which allow for online, real-time, secure access to information. The type of information includes clinical research, outcomes and benchmarking, e-prescription, coding, insurance verification, and claims adjudication. In addition, this information can be available not just to the provider/physical therapist but also to the patient, referral source, and employer.

Petrie: There are several. Tight integration with the patient-scheduling system to ensure that every patient is billed and that their documentation is complete; automatic generation of summary reports to referring physicians and payors; comprehensive workflow solutions versus stand-alone documentation systems; and electronic communication with referring physicians and payors. EMR software is most effective when it is part of a complete solution that creates a new, more efficient workflow for the clinic and not just a replacement for manual charting methods.

Stone: There are many exciting breakthroughs in EMR software products that will save money, time, and frustration. Therapists and rehabilitation directors, who practice in one of the country’s most information-intensive industries, will benefit more than most with EMR information technology.

Welty: The most exciting breakthrough is the ability of some applications to generate and post charges from the clinical records. With the use of rules within applications, providers can now cut out the need for duplicate data entry.

Julie Z. Lee is a contributing writer for Physical Therapy Products.