September 7, 2022
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Dr. Viktoria Davis: If you are billing appropriately and correctly, you don’t have to worry about if you do happen to get audited. The most important thing is that you can substantiate what you’re billing and that your charts can support what you’re billing.
Dr.Bethany Fishbein: Hey! Welcome back to the Power Hour Optometry podcast. I am Bethany Fishbein, host of the podcast and CEO of the Power Practice. And we’re continuing my series that we fell into accidentally of things that strike fear in optometrists. We’ve gone from violence in the office up to and including an active shooter situation, jumped over to Medical Malpractice, and we’ll round out and hopefully, finish this series today with the other terrifying item in the Trio which is a potential of an Insurance Audit. Probably after this, people are going to email me and we’ll think of other things and there’ll be more parts. But this is what we’ve got for now. So my guest today is Dr. Viktoria Davis. And Viktoria is a private practice optometrist. She’s one of our consultants at the Power Practice. She’s our Director of Billing and Coding. She’s been a guest on the podcast before. And Viktoria is the one behind our service. It’s called a Power Audit which we’ll talk about in a moment. But it’s kind of a friendly insurance audit. A way to see how you’re doing without all the fear that goes with her real audit. And we can talk about that. But for now, Viktoria, thank you for coming on again.
Dr. Viktoria Davis: Thank you for inviting me. It’s always a pleasure. It’s always fun to chat with you.
Dr.Bethany Fishbein: I think when we did this last time, it was one of the first times I had ever recorded and was figuring all this stuff out. So now, hopefully, I got a little experience under my belt and we can get things running smoothly here.
Dr. Viktoria Davis: Hopefully so. You never know. Technology always can have glitches. I was at a doctor’s appointment with my daughter the other day and they were in the middle of doing a procedure and the power went out in the entire building. Which was a little terrifying as well in a different way to strike fear into hearts. But you never can predict everything that’s going to happen and that perhaps is something that dovetails well into the strike fear into hearts because I am, as you well know Bethany, a huge planner. If I had my way there would never be any surprises in life. And you never know what life is gonna throw at you. But there are certainly ways to prepare for some things. And I guess that’s what we want to talk about today.
Dr.Bethany Fishbein: Absolutely and thank you for the segue and I appreciate it. That’s been the message, right? You can’t control these things that are going to happen. But controlling the things that you can, and knowledge, and preparation just helps get you set. So that when something does happen, you are absolutely as prepared as possible. And that’s what we’re trying to do here. We’ll talk about some of the things that you see when you do Power Audits in a practice. And what are some of the common things that could get somebody in trouble in the event of a real audit. That, hopefully, somebody listening hears these and says, “Oh! Maybe I do that.” and takes a look at their own charts and corrects it before an audit ever takes place. So that if it does, they can say, “ Yeah. So what? Yeah, it’s a little bit stressful, but I know I’m doing the right thing.” And that’s really what we want.
Dr. Viktoria Davis: Exactly.
Dr. Bethany Fishbein: Talk about just the idea of an Insurance Audit in general. Like why are they done? What are they looking for? Why does that even exist?
Dr. Viktoria Davis: So the biggest reason why audits exist is because the insurance companies want to make sure that their money is going to things that are actually legitimate items and legitimate reasons. It’s kind of like the same way that people may track their own personal expenses or, you know, look at their credit card statement when it comes through rather than just paying it all and never checking anything on it. There certainly are people that do that but it’s not recommended because you want to know where your money’s going. And in case some of it is being misdirected, particularly fraudulently misdirected. You know, like I say it’s like your credit card. If somebody’s using your credit card and you don’t know it, that’s bad. And the only way to know that is if you watch it and you keep track of it. And that sort of is the same idea behind an Insurance Audit. The insurance company wants to make sure that their money is being used for actual real legitimate medical purposes. The way that they do that, they can’t just, you know, pull up a credit card statement and say, “Oh, yeah, that looks right.” They have to, you know, their way of doing that is to ask. Well, originally, to run kind of a report and see what looks like it’s outside of normal. That’s typically the way that an audit starts. Seeing unusual billing trends from a particular practice or provider or things like that. There are some random audits as well. So it doesn’t necessarily mean that you got “flagged” for lack of a better term. But basically they’re just saying, “Hey, is our money going to legitimate purposes? And are we paying you for things that you actually did? And can you substantiate that?” It’s, again, going back to the analogy of your credit card statement. It’s kind of like looking at the statement and then going and checking the receipt or something like that and saying, “Oh, yeah, that is legitimate.”
Dr.Bethany Fishbein: So there are some that are just random like your number came up and they’re gonna look at you for no apparent reason. And then there’s some, like you said, that can get flagged because of unusual billing practices. Do you know what some of those unusual billing practices in optometry could be?
Dr. Viktoria Davis: Well, this is something which I always kind of object to with a lot of my fellow code-heads or things like that. When they’ll say something like, “Oh, you don’t want to bill, for example, a level five office call because that’s a red flag.” And I completely and totally disagree with that. Because like you were saying in the beginning, if you are billing appropriately and correctly, you don’t have to worry about if you do happen to get audited. The most important thing is that you can substantiate what you’re billing and that your charts can support what you’re billing. So you know, although it is not typical for optometrists to bill, you know, a huge number of level five office calls, there may be practices that do. You know? As you know Bethany, from your low vision practice, some of those low vision patients take a lot of time. Particularly now that office calls can be billed strictly on time. You know, if you spend more than 54 minutes with an existing patient, that’s a level five office call. So like I say, your low vision practices, your rehab practices, things like that. You may be getting a lot of level five office calls. There’s not a reason for you not to bill that even though that may be outside the norm for most optometry practices. I always say it’s kind of like the old phrase, “It’s not rare if it’s sitting in your chair.” You know? It’s as far as disease goes. Your billing as long as you’re billing it accurately and appropriately is unique to your practice. And that may mean that it’s not unique to the practice down the street or others in the state or in the nation, and that’s okay.
Dr.Bethany Fishbein: So when you’re selecting codes and you’re doing the billing, really, it shouldn’t be about worrying about whether what you do is going to trigger an audit. It just has to be about making sure that it’s appropriate for what you’re doing.
Dr. Viktoria Davis: It is and making sure that your chart supports that. You know? That you are actually billing and coding and developing that code off what your chart says. Not necessarily what you remember from the exam. Not that you know that you did what your chart says that you did.
Dr.Bethany Fishbein: So if you get audited, and we’ve gotten those letters in the practice, I mean, they’ve been presumably for random audits. But I guess you don’t really know. If you get that letter that says, “We’re reviewing our charts, can you please send the records for these 10 encounters? That’s an audit. Right? Is that an audit?
Dr. Viktoria Davis: That is an audit. Yes, that is absolutely an audit. Yeah. In some cases. I mean, there’s all sorts of different things that there can be audits for as well. There can be audits of certainly for insurance billing, which is kind of what we’re talking about today. There can be audits that insurance companies run to make sure for example, that diabetic patients actually are getting their eye exams. That’s something which has been pretty common in certainly in our state. As there’s been more emphasis on, you know, proper care and coordinated care and things like that. So we will not infrequently get what are called the HEDIS audits. I don’t even know if that’s how you say it. But it’s HEDIS which basically is health, education, and information. I forget what it stands for. But anyway, basically, they aren’t auditing our billing and coding. What they’re auditing is they’re actually making sure that their patients are getting or that they’re insured people are getting appropriate care. And they have on record that this person saw an eye doctor, so they’re making sure that they actually got a Dilated Fundus exam.
Dr. Bethany Fishbein: So that’s actually like a quality control audit? Not a billing audit?
Dr. Viktoria Davis: Exactly. And those, I mean, we get those very commonly in my practice. It’s something that, I don’t know, if it’s just a Minnesota thing or if it’s a nationwide thing. But like I said, certainly in Minnesota. We get those all the time. That just say, “Hey, we want these charts just to make sure that this patient actually had these the services.” which is they’re making sure that they’re doing a good job taking care of their insured clients which I think is a good thing.
Dr.Bethany Fishbein: So usually you get that request for the charts. It’s a little bit stressful just because you have to print everything out and it’s just like a pain to do it. Then you send them in and ideally, nothing really happens after that, right? So if nothing really happens, that means that you probably pass that audit?
Dr. Viktoria Davis: Correct.
Dr. Bethany Fishbein: They looked at it. They saw it. They wanted to see everything was fine and then it goes away. But what happens if they look and then they see something that doesn’t make sense to them? What could happen from there? What’s the scary part?
Dr. Viktoria Davis: It depends on the insurance company. Each insurance company will handle things a little bit differently. So, you know, the experience that I talk about, you know, there certainly are going to be listeners who say, “Oh, well that’s not right. That’s not what I had.” And don’t send emails to Bethany because, you know, every insurance company could treat things differently. But certainly, if there is something that they find that they are concerned about then typically they will send a letter that says there were errors that were found, you know, in your coding or your charting or things like that. Frequently that letter will say, at least in general, what the problem was. The big scary part about it is that frequently there is a dollar amount that is attached to this letter that says, “Because of what we found here, you have to pay us back some sum of money.” The thing which is most scary about this for doctors is that usually insurance companies will extrapolate based on their audits. So in other words, if they asked for 10 charts and they found three of them with audit problems, you know, with problems, be it insufficient records to support the code that you selected or whatever, they won’t just ask for the money back on those three charts. They will ask for the money back on 30% of the services that you billed in that category with that insurance company. So if you billed 1000 of those codes, they’re going to ask for money back on 300 of them. And that’s where things get, you know, dollars add up and things get scary.
Dr.Bethany Fishbein: Does it happen anymore that they send a person to visit? Or is it all like mail and electronic now? I remember the early days of practice, like an auditor, came to the office unannounced.
Dr. Viktoria Davis: I’m sure that there still are some insurance companies that do that. This was another era in which COVID kind of changed things a little bit because insurance companies couldn’t send people out into you know, health care practices, and people couldn’t show up on announced and things like that. And I think they realized that they could get a lot more work done if they didn’t have to travel and if they just stayed home and evaluated their charts at home or in the office. So most of them now are done either by sending the chart somewhere and then with processes done via electronic communication or by mail. Like I say, that’s no guarantee that there isn’t some insurance company that still sends those auditors out in person but it is the exception rather than the rule at this point.
Dr.Bethany Fishbein: And I don’t know if you know, I mean, I guess we’re just guessing but are they looking for accidents? Are they really looking for fraud and sometimes finding carelessness? You know, like you see these articles in the newspaper or online or whatever about, you know, somebody’s billing for podiatry services for patients who don’t even have feet. There’s a big fraud. And when an optometrist gets this, there’s some for optometry too. I’ve seen those. But the average optometrists doing a good job when they get this, you know, you saw the patient you know, you took care of the patient, you know, you did stuff. Is there a delineation or both of those just things that audits can catch?
Dr. Viktoria Davis: It really is just things that audits can catch. I mean, they’re really looking for the big fraud, they care a whole lot more if somebody you know fraudulently claimed $10 million in claims for people who were all dead on that data service. Then if you billed a level four and only had documentation for a level three, you know? I mean they care more about the big fraud stuff but that doesn’t mean that they aren’t going to catch the little stuff as well.
Dr.Bethany Fishbein: So they’re just kind of casting their net or something triggers it and they see what they’re going to see. And if they see something that they don’t like, they can take back money for not only the services that they looked at but for some, whatever they think that represents over the amount of time that you’ve worked with them or that they’ve determined as appropriate. So that’s pretty scary. I get why people worry about that. And so when you do these Power Audits, we call it a friendly audit, which is that you’re really just doing it for the sake of information.
Dr. Viktoria Davis: Exactly. Correct. By the time, and one thing that I was going to mention back when you were talking about the process, you know, they asked for these charts and then you have to send them. My personal recommendation is that the doctor not be involved in pulling and copying those charts that the insurance company asks for. Because by the time that they’ve asked for charts, it’s too late to fix anything. One of the worst things that you can do.
Dr.Bethany Fishbein: So you don’t advise going back to change them? Is that it?
Dr. Viktoria Davis: Correct. At that point, right? And that’s something which is tempting to do, you know? Because you might look over them and be like, “Oh my gosh, I didn’t write this down.” or “I didn’t record this.” or “This isn’t completed or whatever.” Don’t try and change things in your charts after they’ve already requested the chart. That smells bad. So you know? So like I say, I recommend even just having a staff member do it. Because what’s in your chart is in your chart. But the whole point of the friendly audit is to let you know what things are looking like now and how you can do better in the future. It’s kind of like, you know, if you have a heart attack, you want to stop smoking. But it’s not really going to help the heart attack if you stop smoking right now. The train has already left the station there but that doesn’t mean that you can’t improve things for the future.
Dr.Bethany Fishbein: Yeah. And I mean, the example that you gave, right? Of if the doctor pulls the charts and looks at them with that critical eye if they get the audit and they pull the charts themselves and they look and they say, “Oh no, I forgot to enter this. I didn’t record this. I didn’t know what this was or whatever.” That’s a sign, right? That they can analyze in that manner. And so it’s just making the time and making it a priority to do that periodically every two years or two to make sure. And then?
Dr. Viktoria Davis: Exactly. Yes. Absolutely. If doctors are comfortable with their own billing, and they think that they know what they’re doing, and they think that they’re doing things right, and stuff like that. I very highly recommend that they themselves pull, you know, some handful of random charts, you know, 10-20 charts a year or something like that. Go through them and look at them and be like, “Okay, am I doing this right?” or “Oh, wow, have I forgotten something? Do I need to change something?” Because it just happens that we slip into habits or our staff does or things like that and you don’t know if you don’t know? So it’s always a good idea to do those internal audits or self-audits as well. No, of course, if you don’t know what you’re looking for, and then that maybe isn’t terribly helpful, and that’s when getting a friendly audit done first to teach you what you’re looking for is a very good idea.
Dr.Bethany Fishbein: Okay, so let’s kind of get into the substance of that. When you do those, I want to talk about some of the things that you see pretty commonly. Just common errors that could get an office in trouble if they got into one of these. Maybe people can hear this and go back and recognize something they do and correct it. So what are some of the like super common easy-to-fix mistakes that you see when you do this?
Dr. Viktoria Davis: Probably the number one thing that I see, well, pretty much all of them have to do with documentation first. So many of the errors that I see in charts are purely due to documentation errors. Whether that be items that are missing from the chart or documentation within the chart which is internally inconsistent. We’ll talk about that in a little bit. Or, you know, reports that are incomplete or charts that are unsigned. Those are all documentation sorts of things. But the one that I really find most commonly that people don’t even think about is that an individual chart needs to stand on its own. Now what I mean by that is that an auditor, were they to come in, you know, or request the chart. They can only request the chart for a given timeframe, a given, you know, range of dates. But I have patients that I’ve been seeing for, you know, all 25 years I’ve been in practice. They are not going to be able to request that chart. They can’t even look at things that are outside the specific timeframe of their audit. And so that means that you can’t just reference, “See previous history.” or something like that. It needs to be stated explicitly in each chart, what they’re there for. And, you know, if they’re somebody with glaucoma or something like that, you know, you can’t just say, “Same as previous.” or something, you know? The chart has to be able to stand on its own. One of the things which I see most consistently as well is that it is very frequently not explicitly recorded whether a patient is a new patient or an established patient. So you’re reading through the chart, you know, as an auditor. You’re reading through the chart and you have no idea if this patient has been seen in this practice before or not, which can dramatically change how you’re looking at the chart. And not only that, it can obviously, will change your billing. The code which is selected. And if it appears that it was an established patient, but they billed a new patient code, that’s going to be a problem. So I always recommend that practices state very, very clearly on the chart, “Existing Patient” or “New Patient” here or “Last exam here” and the date or something like that. So that it is extraordinarily clear, right off the bat, whether it’s a new patient or an established patient.
Dr.Bethany Fishbein: That’s like true, right? That’s if you’re writing a chief complaint, blurry vision, right? Or chief complaint, eye pain, and the patient report it’s resolving. And you saw that they can’t tell from that if you’ve been seeing that patient for three weeks in a row following a corneal ulcer or are seeing them for the first time that day. Right?
Dr. Viktoria Davis: Correct.
Dr. Bethany Fishbein: So like every time, you have to have the meds and the Family History. You can’t write, “Unchanged from the previous.”? So if your EHRs make it pretty easy, right, you can copy that from last time. But in a paper chart, if doctors are still using that, meds, etc, it should be recorded every single time,
Dr. Viktoria Davis: Correct. Yep.
Dr. Bethany Fishbein: Wow. Okay.
Dr. Viktoria Davis: Yep. And you bring up an interesting point. As far as EHRs make things easy what you can bring forward, that leads to the next most common thing that I see, which is improper use of pull forward in EHRs. Because it is so easy in those EHRs to pull forward findings. And this is particularly done and this is kind of another instance of something that I see commonly, is your chief complaint has to drive your exam. So if your chief complaint which is listed is that the patient feels like they got something in their eye. They were out grinding yesterday afternoon without eye protection or you know. You can tell I’m in a rural area. This is your chief complaint and this will make sense. And then you go through the chart, and there’s a recording of a Fundus examination. That chief complaint does not, you know, like you may have that you removed, you know, piece of metal from the eye or whatever. But there’s no medical reason to have a Fundus exam there. And maybe you just accidentally hit the pull forward button and put that in there. If there’s a reason why you have it if you’re like concerned about a penetrating foreign body or you know, something like that, then I mean. I’m trying to figure out a reason why you might medically need to do a Fundus exam in this example. But, you know, I always try to give people the benefit of the doubt. But most of the time, it’s not recorded why they needed to do those kinds of things and it is just a case of an inadvertent pull forward.
Dr.Bethany Fishbein: Before you go on to the next. That one is super easy to do, like, especially I mean, I’ve seen it in practices. A patient has a red eye or something and all of a sudden they’ve had that red eye for years in the chart. And they probably one year stopped having it very shortly after the first time they did have it. But yes, okay. So it makes it easier because you’re not writing out a whole list of meds. But it also opens you up to be lazy and just copy forward without looking which is a problem.
Dr. Viktoria Davis: Yes, some EHRs give different categories of pull forward. So you may be able to pull forward an entire exam so that, you know, and that sounds awesome. You’re like, “Oh, I can pre-populate this whole exam as normal or something,” Because, “Oh, it’s probably going to be, you know.” or pre-populated from what they had before. Or you can pull forward sometimes like one page on the screen, or you can pull forward an individual test like a slit lamp exam and pull forward that section. I personally recommend that you pull forward as small a section as possible, because otherwise, it’s way too easy to miss that you didn’t do something on this exam, you know. That, “Oh yeah. On this exam, I didn’t. I don’t know. Do Gonioscopy or something.“ But, “Oh, look, my chart says that I did.” You know? Because I just use the pull forward entire exam, but I mean, I don’t know. I’m just kind of pulling things out. But it is so easy to inadvertently record the same data using pull forward.
Dr.Bethany Fishbein: I’m thinking about Eisah in our practice. We were recording height and weight, you know, when you had to do that for the reporting or whatever. We started doing that and that got pulled forward along with medical history. So you would have this patient in the chair right before they’re leaving for college, you know. Six foot two to go play soccer or whatever at university and you look and it says their height is four three and they weigh 61 pounds. I’m like, “Yeah, okay, probably guilty of doing that.” And really, the thing is, once you sign and close your chart for the day, whatever’s in there, you’re saying, “This is what I did.”, Right? Like that’s what kind of signing the chart is about. It is you’re putting your stamp of approval on whatever is in there. And so, if it’s not accurate, it doesn’t matter because you put your name or your initials or whatever you said it was.
Dr. Viktoria Davis: Yeah, technically when you sign a chart, you are certifying you as the doctor. You are certifying and attesting that all of the information contained in the chart is complete and correct to the best of your knowledge.
Dr.Bethany Fishbein: Okay. So look at the chart, and make sure that that’s actually true. It is a big thing to do to just protect yourself. So that if you are audited, you have a better likelihood of passing.
Dr. Viktoria Davis: Correct Yep.
Dr. Bethany Fishbein: Talk about signing the charts because I remember that came up in a Power Audit that was done with one of our clients. And it honestly was something that I didn’t even know. That even if it’s a solo doctor in practice and one doctor is seeing every single one of the patients, they still have to sign their chart.
Dr. Viktoria Davis: Absolutely. Yep. And this, again, goes back to the you as the doctor are certifying that all the information in the chart is complete and correct to the best of your knowledge. Is that if you don’t sign your chart, then nothing in there. Basically, if you don’t sign the chart, nothing was done as far as any insurance company or legal entity would accept. Because it is not like I say, “You have not attested to that. You have not certified that the chart is correct.” And so even in a solo practice, and most of the reason for that is because in most like EHRs and things like that, you know, staff may be able to go in and change things. Until the chart is signed. Typically once the chart is signed in any EHR, it’s much more difficult to go in and change things. There’s a reason for that. Back when we use paper charts, I remember when I was even like in school and stuff, it was always recommended that you used black ink for like for all your findings on that day once you sign the chart. But if you had to change something, for whatever reason, make a correction or whatever, then you use blue ink to do that. I have no idea if that was just something that I heard or put. I mean it makes sense. Because again, then you’re showing what was done when and once that chart is signed, that chart is complete. But until it’s signed, it’s not. You also shouldn’t bill anything until it is signed.
Dr.Bethany Fishbein: That’s kind of a mindset shift because I think most I don’t know a lot of doctors see the signing of the chart as indicating, “I saw the patient.” Right? Especially in a multidoctor practice. When I signed a chart, it means I saw them instead of my husband or somebody else. And always that’s it. So I think shifting that to the blurb that you said you know, “I attest that everything in here is correct, etc.” is a good mindset. What’s another common thing?
Dr. Viktoria Davis: Probably another common thing I see is for like documentation on special testing. Things like photography, OCTs, visual fields, and things like that. That documentation doesn’t have to be incredibly elaborate. But it does need to include more than just, “Testing was normal.” or “Testing was unchanged.” or things like that, you know? And that’s something that I see a lot, is that that documentation on that special testing is very limited at best. For any special testing that’s done, you need to have clearly in the chart the reason why it was done and why that specific special testing was done so far. In other words, if you have a patient with, you know, glaucoma. “Okay, you want to do an OCT, you know optic nerve head, or CT. Then your reason for testing would be primary open angle glaucoma, monitor progression, and guide treatment. That’s the reason why you’re doing that. It’s not just because they have glaucoma. It’s because you are monitoring the progression of their glaucoma and guiding their treatment. And then you also need to state the results of it. So what things look like. Most of our testing that we do has some numerical values that are associated with it. It’s always an easy thing to put those numerical values in. Some EHRs will let, you know, and automatically import those numerical values from your instruments and things like that. And that’s totally fine. Otherwise, even just a brief analysis of what it is, you know, what the results of it were? And then any comparison to previous. Insurance companies love to see, you know. That again, that monitor progression and guide treatment. They want to know if things have changed. And that’s what we’re looking for. So basically it is just documenting what your brain is thinking. You know what you’re looking for when you do this. And then in that case saying, “No change from previous as your comparison is probably sufficient if you’ve stated what your results are also. And then also your recommendations. So what are you going to do about it? What happened? What are your results from this? And that could be continued Latanoprost, one drop of qHS, return three months or whatever. But why do you want this test? What is it going to do to help you? What the results of it were? What changes you saw? and what you’re going to do from it. And that’s really what needs to be documented. Like I say, this does not have to be a huge multi-page thing. This doesn’t even have to be really a multi-sentence kind of thing. One thing which I think can help all of us as optometrists now is the fact that almost every general practice healthcare these days have patient portals. And anybody who’s ever had any imaging or scans done whether that be you know, an x-ray on a broken bone or whether that be, you know? A routine mammogram or things like that. You can look on your patient portal and see what that radiologists report looks like. That’s very similar to what our special testing reports need to look like. It’s the same guidelines there’s nothing which is different for optometry as opposed to anything else. And they’re going to do the same things there. You know, as far as what they’re saying, Why did you have to have this done? What did you find? If there was a comparison to the previous, what any changes were and what they’re going to do about it? And that’s like I say exactly the same things that they’re presenting in their reports or things that we’re presenting in our reports as well. And that lack of documentation on those special testing is fairly rampant in optometry.
Dr.Bethany Fishbein: Yeah, I imagined that to be so. Before we close here, give an example of some of the crazy ones. Of things that you don’t see too often but you’ve seen once or twice that really could have gotten this doctor in trouble.
Dr. Viktoria Davis: So one of them and this kind of again, goes back to EHR documentation. And this is kind of talking about what I mentioned earlier, internal inconsistency in charts. I have no idea how this doctor’s EHR was set up. But somehow, the same test was recorded multiple times in an encounter once as normal and once as a problem. So basically, the doctor would go through and push the normal button and normalize the chart. And then if there were wrong things, then he’d go back and change those. So the same test was in the charts that I was auditing multiple times with different results.
Dr.Bethany Fishbein: I mean, that can’t be right, no matter which way it goes. Because it can’t be both?
Dr. Viktoria Davis: Exactly . It can’t be both right. It can’t be both. I mean, even down to things like CD ratios being recorded differently in two different spots in the chart. And I had a really, really hard time doing this audit because I couldn’t figure out why it was done. And like I say, when I’m doing a friendly audit, in particular, I’m always trying to give the doctor the benefit of the doubt and say, “Okay, it looks like this and you know, kind of trying to get inside their brain a little bit and I literally could not tell what was done. And most auditors at that point would have just thrown in the towel and said, “I can’t figure this out and so they don’t deserve any money.”
Dr.Bethany Fishbein: Yeah, so there’s an advantage of having a friendly auditor.
Dr. Viktoria Davis: Definitely. So and then the other. This is one that I heard of. I did not personally see this, so I can’t actually vouch for it, but I heard it from the doctor who was doing it and I mentioned this actually on the other podcast that I did with you. With a doctor who was really trying to work the system for insurance. And so for special testing codes, which are either unilateral or bilateral, some macular or binocular, or things like OCTs and visual fields and stuff like that. He would have the patient in one day to do one eye. And then like a few weeks later to do the other eye. And bill for both of those. And there’s a lot of reasons why.
Dr. Bethany Fishbein: He billed twice?
Dr. Viktoria Davis: Yes.
Dr. Bethany Fishbein: And an office visit for each?
Dr. Viktoria Davis: I don’t know for sure whether they billed an office visit for each if you’re doing just a standalone visit. Like all you’re doing is a field then, you know if you’re not spending any time with the doctor and it’s just with the technician then typically there’s not an office call that’s billed along with that. But yeah, he’d be like, “Oh yeah, they came in to get their glasses adjusted and so we just stuck them in for an OCT on one eye and then billed for it.
Dr.Bethany Fishbein: That crosses the line from, “Oopsie. I hit the copy Forward button.” to “I figured out a loophole and want to get paid for two fields every time I do one instead of one.”
Dr. Viktoria Davis: Exactly.
Dr. Bethany Fishbein: But I mean that exists out there. Somebody’s looking for the loopholes is probably not going to be the conscientious one saying, “I’d like a friendly audit.” They know, right? That they probably wouldn’t pass and are just taking their chances.
Dr. Viktoria Davis: Right? Correct.
Dr. Bethany Fishbein: Okay.
Dr. Viktoria Davis: The much more common thing that I see and this isn’t necessarily something that’ll, you know, get you in trouble. But it’s just something which is not the smartest thing to do from a billing standpoint or bottom line standpoint, is the doctor who is so afraid of an audit that they just downcode everything, you know? For example, they’ll say, “Oh, well, optometrists. I’ve heard that they never should bill a level five. So just to be safe. I’m gonna bill level three on everything. And, you know, insurance companies don’t like that either. They really want you to bill properly, you know, and appropriately. So even though you know, they aren’t just out to get you. And I don’t think insurance companies for the most part are out to get you. Some of them may want to bleed you dry but that gets into a whole different issue. But, you know, they want you to bill properly and appropriately and bill based on what you actually did and what’s in your chart.
Dr.Bethany Fishbein: Yeah. I know that. That certainly comes up I remember you did a webinar for our Power Practice clients on “Don’t Fear the Four” and it was all about level four offices and codes. And that was really the feedback that we got afterward. It was a lot of people saying, “Wait, I’m doing this and I’m coding. I’m coding for level three because I was afraid.” And that fear can be depending on the company, a $30, $40,or $50 encounter. So learning that and getting over that fear is important. Okay.
Dr. Viktoria Davis: Yes. And one other thing I wanted to mention here. Also when we’re talking about the process of an audit and what happens if you do get audited and when you do get that letter. There frequently, almost always, there is an opportunity for you to appeal the audit or to explain your charts in your auditing. You know, explain your side of the story. And that is always something that I encourage doctors to do. Again, if they believe in their coding and if they believe their charts are correct, then, by all means, explain it. There’s no reason just to take what they say just because they’re a big company or something like that.
Dr.Bethany Fishbein: That explanation, does that go with, “Okay, we’re just requesting 10 charts.” They might have just been your random turn or do you appeal when they say, “Three of these charts you didn’t have appropriate documentation for the code and we want $14,000.” Like when do you appeal? Or is it if they request those charts and then you look and you realize you didn’t sign them? And you copied forward and you have inconsistent findings, etcetera, etcetera, etcetera? And you think, “Okay, I’m gonna fail this.”
Dr. Viktoria Davis: Don’t give them more information than they asked for. That’s another kind of big thing is that you know, give them exactly what they asked for and only what they asked for. So don’t volunteer information, you know. Even if you looked at the charts and you’re like, “Oh my gosh! I totally messed this up should I say something?” No. Let them look at it first. And if they say that something’s wrong, you know, then follow up with that.
Dr.Bethany Fishbein: Gotcha. All right, Viktoria. Thank you. You have the unique ability to make insurance interesting and give good advice and solid things that people should know and really feel doable if you just pay attention to them. If somebody wants to find out more, or is interested in getting a Power Audit, where do they go for information?
Dr. Viktoria Davis: They really can go to the Power Practice website, which is www.powerpractice.com. And there is a tab there that talks about the Power Audit and that’s really where more information is. There are also email addresses on there as well and we’ll come to shoot off an email and somebody will get back to you.
Dr.Bethany Fishbein: Awesome. Thank you so much for taking the time once again and sharing all of this useful information. To take something that sounds really scary and makes you realize it doesn’t have to be as long as you’re doing what you’re supposed to. So thank you so much. Thank you for listening.
Dr. Viktoria Davis: Thank you. I enjoyed it.
Read the Transcription
Dr. Viktoria Davis: If you are billing appropriately and correctly, you don’t have to worry about if you do happen to get audited. The most important thing is that you can substantiate what you’re billing and that your charts can support what you’re billing.
Dr.Bethany Fishbein: Hey! Welcome back to the Power Hour Optometry podcast. I am Bethany Fishbein, host of the podcast and CEO of the Power Practice. And we’re continuing my series that we fell into accidentally of things that strike fear in optometrists. We’ve gone from violence in the office up to and including an active shooter situation, jumped over to Medical Malpractice, and we’ll round out and hopefully, finish this series today with the other terrifying item in the Trio which is a potential of an Insurance Audit. Probably after this, people are going to email me and we’ll think of other things and there’ll be more parts. But this is what we’ve got for now. So my guest today is Dr. Viktoria Davis. And Viktoria is a private practice optometrist. She’s one of our consultants at the Power Practice. She’s our Director of Billing and Coding. She’s been a guest on the podcast before. And Viktoria is the one behind our service. It’s called a Power Audit which we’ll talk about in a moment. But it’s kind of a friendly insurance audit. A way to see how you’re doing without all the fear that goes with her real audit. And we can talk about that. But for now, Viktoria, thank you for coming on again.
Dr. Viktoria Davis: Thank you for inviting me. It’s always a pleasure. It’s always fun to chat with you.
Dr.Bethany Fishbein: I think when we did this last time, it was one of the first times I had ever recorded and was figuring all this stuff out. So now, hopefully, I got a little experience under my belt and we can get things running smoothly here.
Dr. Viktoria Davis: Hopefully so. You never know. Technology always can have glitches. I was at a doctor’s appointment with my daughter the other day and they were in the middle of doing a procedure and the power went out in the entire building. Which was a little terrifying as well in a different way to strike fear into hearts. But you never can predict everything that’s going to happen and that perhaps is something that dovetails well into the strike fear into hearts because I am, as you well know Bethany, a huge planner. If I had my way there would never be any surprises in life. And you never know what life is gonna throw at you. But there are certainly ways to prepare for some things. And I guess that’s what we want to talk about today.
Dr.Bethany Fishbein: Absolutely and thank you for the segue and I appreciate it. That’s been the message, right? You can’t control these things that are going to happen. But controlling the things that you can, and knowledge, and preparation just helps get you set. So that when something does happen, you are absolutely as prepared as possible. And that’s what we’re trying to do here. We’ll talk about some of the things that you see when you do Power Audits in a practice. And what are some of the common things that could get somebody in trouble in the event of a real audit. That, hopefully, somebody listening hears these and says, “Oh! Maybe I do that.” and takes a look at their own charts and corrects it before an audit ever takes place. So that if it does, they can say, “ Yeah. So what? Yeah, it’s a little bit stressful, but I know I’m doing the right thing.” And that’s really what we want.
Dr. Viktoria Davis: Exactly.
Dr. Bethany Fishbein: Talk about just the idea of an Insurance Audit in general. Like why are they done? What are they looking for? Why does that even exist?
Dr. Viktoria Davis: So the biggest reason why audits exist is because the insurance companies want to make sure that their money is going to things that are actually legitimate items and legitimate reasons. It’s kind of like the same way that people may track their own personal expenses or, you know, look at their credit card statement when it comes through rather than just paying it all and never checking anything on it. There certainly are people that do that but it’s not recommended because you want to know where your money’s going. And in case some of it is being misdirected, particularly fraudulently misdirected. You know, like I say it’s like your credit card. If somebody’s using your credit card and you don’t know it, that’s bad. And the only way to know that is if you watch it and you keep track of it. And that sort of is the same idea behind an Insurance Audit. The insurance company wants to make sure that their money is being used for actual real legitimate medical purposes. The way that they do that, they can’t just, you know, pull up a credit card statement and say, “Oh, yeah, that looks right.” They have to, you know, their way of doing that is to ask. Well, originally, to run kind of a report and see what looks like it’s outside of normal. That’s typically the way that an audit starts. Seeing unusual billing trends from a particular practice or provider or things like that. There are some random audits as well. So it doesn’t necessarily mean that you got “flagged” for lack of a better term. But basically they’re just saying, “Hey, is our money going to legitimate purposes? And are we paying you for things that you actually did? And can you substantiate that?” It’s, again, going back to the analogy of your credit card statement. It’s kind of like looking at the statement and then going and checking the receipt or something like that and saying, “Oh, yeah, that is legitimate.”
Dr.Bethany Fishbein: So there are some that are just random like your number came up and they’re gonna look at you for no apparent reason. And then there’s some, like you said, that can get flagged because of unusual billing practices. Do you know what some of those unusual billing practices in optometry could be?
Dr. Viktoria Davis: Well, this is something which I always kind of object to with a lot of my fellow code-heads or things like that. When they’ll say something like, “Oh, you don’t want to bill, for example, a level five office call because that’s a red flag.” And I completely and totally disagree with that. Because like you were saying in the beginning, if you are billing appropriately and correctly, you don’t have to worry about if you do happen to get audited. The most important thing is that you can substantiate what you’re billing and that your charts can support what you’re billing. So you know, although it is not typical for optometrists to bill, you know, a huge number of level five office calls, there may be practices that do. You know? As you know Bethany, from your low vision practice, some of those low vision patients take a lot of time. Particularly now that office calls can be billed strictly on time. You know, if you spend more than 54 minutes with an existing patient, that’s a level five office call. So like I say, your low vision practices, your rehab practices, things like that. You may be getting a lot of level five office calls. There’s not a reason for you not to bill that even though that may be outside the norm for most optometry practices. I always say it’s kind of like the old phrase, “It’s not rare if it’s sitting in your chair.” You know? It’s as far as disease goes. Your billing as long as you’re billing it accurately and appropriately is unique to your practice. And that may mean that it’s not unique to the practice down the street or others in the state or in the nation, and that’s okay.
Dr.Bethany Fishbein: So when you’re selecting codes and you’re doing the billing, really, it shouldn’t be about worrying about whether what you do is going to trigger an audit. It just has to be about making sure that it’s appropriate for what you’re doing.
Dr. Viktoria Davis: It is and making sure that your chart supports that. You know? That you are actually billing and coding and developing that code off what your chart says. Not necessarily what you remember from the exam. Not that you know that you did what your chart says that you did.
Dr.Bethany Fishbein: So if you get audited, and we’ve gotten those letters in the practice, I mean, they’ve been presumably for random audits. But I guess you don’t really know. If you get that letter that says, “We’re reviewing our charts, can you please send the records for these 10 encounters? That’s an audit. Right? Is that an audit?
Dr. Viktoria Davis: That is an audit. Yes, that is absolutely an audit. Yeah. In some cases. I mean, there’s all sorts of different things that there can be audits for as well. There can be audits of certainly for insurance billing, which is kind of what we’re talking about today. There can be audits that insurance companies run to make sure for example, that diabetic patients actually are getting their eye exams. That’s something which has been pretty common in certainly in our state. As there’s been more emphasis on, you know, proper care and coordinated care and things like that. So we will not infrequently get what are called the HEDIS audits. I don’t even know if that’s how you say it. But it’s HEDIS which basically is health, education, and information. I forget what it stands for. But anyway, basically, they aren’t auditing our billing and coding. What they’re auditing is they’re actually making sure that their patients are getting or that they’re insured people are getting appropriate care. And they have on record that this person saw an eye doctor, so they’re making sure that they actually got a Dilated Fundus exam.
Dr. Bethany Fishbein: So that’s actually like a quality control audit? Not a billing audit?
Dr. Viktoria Davis: Exactly. And those, I mean, we get those very commonly in my practice. It’s something that, I don’t know, if it’s just a Minnesota thing or if it’s a nationwide thing. But like I said, certainly in Minnesota. We get those all the time. That just say, “Hey, we want these charts just to make sure that this patient actually had these the services.” which is they’re making sure that they’re doing a good job taking care of their insured clients which I think is a good thing.
Dr.Bethany Fishbein: So usually you get that request for the charts. It’s a little bit stressful just because you have to print everything out and it’s just like a pain to do it. Then you send them in and ideally, nothing really happens after that, right? So if nothing really happens, that means that you probably pass that audit?
Dr. Viktoria Davis: Correct.
Dr. Bethany Fishbein: They looked at it. They saw it. They wanted to see everything was fine and then it goes away. But what happens if they look and then they see something that doesn’t make sense to them? What could happen from there? What’s the scary part?
Dr. Viktoria Davis: It depends on the insurance company. Each insurance company will handle things a little bit differently. So, you know, the experience that I talk about, you know, there certainly are going to be listeners who say, “Oh, well that’s not right. That’s not what I had.” And don’t send emails to Bethany because, you know, every insurance company could treat things differently. But certainly, if there is something that they find that they are concerned about then typically they will send a letter that says there were errors that were found, you know, in your coding or your charting or things like that. Frequently that letter will say, at least in general, what the problem was. The big scary part about it is that frequently there is a dollar amount that is attached to this letter that says, “Because of what we found here, you have to pay us back some sum of money.” The thing which is most scary about this for doctors is that usually insurance companies will extrapolate based on their audits. So in other words, if they asked for 10 charts and they found three of them with audit problems, you know, with problems, be it insufficient records to support the code that you selected or whatever, they won’t just ask for the money back on those three charts. They will ask for the money back on 30% of the services that you billed in that category with that insurance company. So if you billed 1000 of those codes, they’re going to ask for money back on 300 of them. And that’s where things get, you know, dollars add up and things get scary.
Dr.Bethany Fishbein: Does it happen anymore that they send a person to visit? Or is it all like mail and electronic now? I remember the early days of practice, like an auditor, came to the office unannounced.
Dr. Viktoria Davis: I’m sure that there still are some insurance companies that do that. This was another era in which COVID kind of changed things a little bit because insurance companies couldn’t send people out into you know, health care practices, and people couldn’t show up on announced and things like that. And I think they realized that they could get a lot more work done if they didn’t have to travel and if they just stayed home and evaluated their charts at home or in the office. So most of them now are done either by sending the chart somewhere and then with processes done via electronic communication or by mail. Like I say, that’s no guarantee that there isn’t some insurance company that still sends those auditors out in person but it is the exception rather than the rule at this point.
Dr.Bethany Fishbein: And I don’t know if you know, I mean, I guess we’re just guessing but are they looking for accidents? Are they really looking for fraud and sometimes finding carelessness? You know, like you see these articles in the newspaper or online or whatever about, you know, somebody’s billing for podiatry services for patients who don’t even have feet. There’s a big fraud. And when an optometrist gets this, there’s some for optometry too. I’ve seen those. But the average optometrists doing a good job when they get this, you know, you saw the patient you know, you took care of the patient, you know, you did stuff. Is there a delineation or both of those just things that audits can catch?
Dr. Viktoria Davis: It really is just things that audits can catch. I mean, they’re really looking for the big fraud, they care a whole lot more if somebody you know fraudulently claimed $10 million in claims for people who were all dead on that data service. Then if you billed a level four and only had documentation for a level three, you know? I mean they care more about the big fraud stuff but that doesn’t mean that they aren’t going to catch the little stuff as well.
Dr.Bethany Fishbein: So they’re just kind of casting their net or something triggers it and they see what they’re going to see. And if they see something that they don’t like, they can take back money for not only the services that they looked at but for some, whatever they think that represents over the amount of time that you’ve worked with them or that they’ve determined as appropriate. So that’s pretty scary. I get why people worry about that. And so when you do these Power Audits, we call it a friendly audit, which is that you’re really just doing it for the sake of information.
Dr. Viktoria Davis: Exactly. Correct. By the time, and one thing that I was going to mention back when you were talking about the process, you know, they asked for these charts and then you have to send them. My personal recommendation is that the doctor not be involved in pulling and copying those charts that the insurance company asks for. Because by the time that they’ve asked for charts, it’s too late to fix anything. One of the worst things that you can do.
Dr.Bethany Fishbein: So you don’t advise going back to change them? Is that it?
Dr. Viktoria Davis: Correct. At that point, right? And that’s something which is tempting to do, you know? Because you might look over them and be like, “Oh my gosh, I didn’t write this down.” or “I didn’t record this.” or “This isn’t completed or whatever.” Don’t try and change things in your charts after they’ve already requested the chart. That smells bad. So you know? So like I say, I recommend even just having a staff member do it. Because what’s in your chart is in your chart. But the whole point of the friendly audit is to let you know what things are looking like now and how you can do better in the future. It’s kind of like, you know, if you have a heart attack, you want to stop smoking. But it’s not really going to help the heart attack if you stop smoking right now. The train has already left the station there but that doesn’t mean that you can’t improve things for the future.
Dr.Bethany Fishbein: Yeah. And I mean, the example that you gave, right? Of if the doctor pulls the charts and looks at them with that critical eye if they get the audit and they pull the charts themselves and they look and they say, “Oh no, I forgot to enter this. I didn’t record this. I didn’t know what this was or whatever.” That’s a sign, right? That they can analyze in that manner. And so it’s just making the time and making it a priority to do that periodically every two years or two to make sure. And then?
Dr. Viktoria Davis: Exactly. Yes. Absolutely. If doctors are comfortable with their own billing, and they think that they know what they’re doing, and they think that they’re doing things right, and stuff like that. I very highly recommend that they themselves pull, you know, some handful of random charts, you know, 10-20 charts a year or something like that. Go through them and look at them and be like, “Okay, am I doing this right?” or “Oh, wow, have I forgotten something? Do I need to change something?” Because it just happens that we slip into habits or our staff does or things like that and you don’t know if you don’t know? So it’s always a good idea to do those internal audits or self-audits as well. No, of course, if you don’t know what you’re looking for, and then that maybe isn’t terribly helpful, and that’s when getting a friendly audit done first to teach you what you’re looking for is a very good idea.
Dr.Bethany Fishbein: Okay, so let’s kind of get into the substance of that. When you do those, I want to talk about some of the things that you see pretty commonly. Just common errors that could get an office in trouble if they got into one of these. Maybe people can hear this and go back and recognize something they do and correct it. So what are some of the like super common easy-to-fix mistakes that you see when you do this?
Dr. Viktoria Davis: Probably the number one thing that I see, well, pretty much all of them have to do with documentation first. So many of the errors that I see in charts are purely due to documentation errors. Whether that be items that are missing from the chart or documentation within the chart which is internally inconsistent. We’ll talk about that in a little bit. Or, you know, reports that are incomplete or charts that are unsigned. Those are all documentation sorts of things. But the one that I really find most commonly that people don’t even think about is that an individual chart needs to stand on its own. Now what I mean by that is that an auditor, were they to come in, you know, or request the chart. They can only request the chart for a given timeframe, a given, you know, range of dates. But I have patients that I’ve been seeing for, you know, all 25 years I’ve been in practice. They are not going to be able to request that chart. They can’t even look at things that are outside the specific timeframe of their audit. And so that means that you can’t just reference, “See previous history.” or something like that. It needs to be stated explicitly in each chart, what they’re there for. And, you know, if they’re somebody with glaucoma or something like that, you know, you can’t just say, “Same as previous.” or something, you know? The chart has to be able to stand on its own. One of the things which I see most consistently as well is that it is very frequently not explicitly recorded whether a patient is a new patient or an established patient. So you’re reading through the chart, you know, as an auditor. You’re reading through the chart and you have no idea if this patient has been seen in this practice before or not, which can dramatically change how you’re looking at the chart. And not only that, it can obviously, will change your billing. The code which is selected. And if it appears that it was an established patient, but they billed a new patient code, that’s going to be a problem. So I always recommend that practices state very, very clearly on the chart, “Existing Patient” or “New Patient” here or “Last exam here” and the date or something like that. So that it is extraordinarily clear, right off the bat, whether it’s a new patient or an established patient.
Dr.Bethany Fishbein: That’s like true, right? That’s if you’re writing a chief complaint, blurry vision, right? Or chief complaint, eye pain, and the patient report it’s resolving. And you saw that they can’t tell from that if you’ve been seeing that patient for three weeks in a row following a corneal ulcer or are seeing them for the first time that day. Right?
Dr. Viktoria Davis: Correct.
Dr. Bethany Fishbein: So like every time, you have to have the meds and the Family History. You can’t write, “Unchanged from the previous.”? So if your EHRs make it pretty easy, right, you can copy that from last time. But in a paper chart, if doctors are still using that, meds, etc, it should be recorded every single time,
Dr. Viktoria Davis: Correct. Yep.
Dr. Bethany Fishbein: Wow. Okay.
Dr. Viktoria Davis: Yep. And you bring up an interesting point. As far as EHRs make things easy what you can bring forward, that leads to the next most common thing that I see, which is improper use of pull forward in EHRs. Because it is so easy in those EHRs to pull forward findings. And this is particularly done and this is kind of another instance of something that I see commonly, is your chief complaint has to drive your exam. So if your chief complaint which is listed is that the patient feels like they got something in their eye. They were out grinding yesterday afternoon without eye protection or you know. You can tell I’m in a rural area. This is your chief complaint and this will make sense. And then you go through the chart, and there’s a recording of a Fundus examination. That chief complaint does not, you know, like you may have that you removed, you know, piece of metal from the eye or whatever. But there’s no medical reason to have a Fundus exam there. And maybe you just accidentally hit the pull forward button and put that in there. If there’s a reason why you have it if you’re like concerned about a penetrating foreign body or you know, something like that, then I mean. I’m trying to figure out a reason why you might medically need to do a Fundus exam in this example. But, you know, I always try to give people the benefit of the doubt. But most of the time, it’s not recorded why they needed to do those kinds of things and it is just a case of an inadvertent pull forward.
Dr.Bethany Fishbein: Before you go on to the next. That one is super easy to do, like, especially I mean, I’ve seen it in practices. A patient has a red eye or something and all of a sudden they’ve had that red eye for years in the chart. And they probably one year stopped having it very shortly after the first time they did have it. But yes, okay. So it makes it easier because you’re not writing out a whole list of meds. But it also opens you up to be lazy and just copy forward without looking which is a problem.
Dr. Viktoria Davis: Yes, some EHRs give different categories of pull forward. So you may be able to pull forward an entire exam so that, you know, and that sounds awesome. You’re like, “Oh, I can pre-populate this whole exam as normal or something,” Because, “Oh, it’s probably going to be, you know.” or pre-populated from what they had before. Or you can pull forward sometimes like one page on the screen, or you can pull forward an individual test like a slit lamp exam and pull forward that section. I personally recommend that you pull forward as small a section as possible, because otherwise, it’s way too easy to miss that you didn’t do something on this exam, you know. That, “Oh yeah. On this exam, I didn’t. I don’t know. Do Gonioscopy or something.“ But, “Oh, look, my chart says that I did.” You know? Because I just use the pull forward entire exam, but I mean, I don’t know. I’m just kind of pulling things out. But it is so easy to inadvertently record the same data using pull forward.
Dr.Bethany Fishbein: I’m thinking about Eisah in our practice. We were recording height and weight, you know, when you had to do that for the reporting or whatever. We started doing that and that got pulled forward along with medical history. So you would have this patient in the chair right before they’re leaving for college, you know. Six foot two to go play soccer or whatever at university and you look and it says their height is four three and they weigh 61 pounds. I’m like, “Yeah, okay, probably guilty of doing that.” And really, the thing is, once you sign and close your chart for the day, whatever’s in there, you’re saying, “This is what I did.”, Right? Like that’s what kind of signing the chart is about. It is you’re putting your stamp of approval on whatever is in there. And so, if it’s not accurate, it doesn’t matter because you put your name or your initials or whatever you said it was.
Dr. Viktoria Davis: Yeah, technically when you sign a chart, you are certifying you as the doctor. You are certifying and attesting that all of the information contained in the chart is complete and correct to the best of your knowledge.
Dr.Bethany Fishbein: Okay. So look at the chart, and make sure that that’s actually true. It is a big thing to do to just protect yourself. So that if you are audited, you have a better likelihood of passing.
Dr. Viktoria Davis: Correct Yep.
Dr. Bethany Fishbein: Talk about signing the charts because I remember that came up in a Power Audit that was done with one of our clients. And it honestly was something that I didn’t even know. That even if it’s a solo doctor in practice and one doctor is seeing every single one of the patients, they still have to sign their chart.
Dr. Viktoria Davis: Absolutely. Yep. And this, again, goes back to the you as the doctor are certifying that all the information in the chart is complete and correct to the best of your knowledge. Is that if you don’t sign your chart, then nothing in there. Basically, if you don’t sign the chart, nothing was done as far as any insurance company or legal entity would accept. Because it is not like I say, “You have not attested to that. You have not certified that the chart is correct.” And so even in a solo practice, and most of the reason for that is because in most like EHRs and things like that, you know, staff may be able to go in and change things. Until the chart is signed. Typically once the chart is signed in any EHR, it’s much more difficult to go in and change things. There’s a reason for that. Back when we use paper charts, I remember when I was even like in school and stuff, it was always recommended that you used black ink for like for all your findings on that day once you sign the chart. But if you had to change something, for whatever reason, make a correction or whatever, then you use blue ink to do that. I have no idea if that was just something that I heard or put. I mean it makes sense. Because again, then you’re showing what was done when and once that chart is signed, that chart is complete. But until it’s signed, it’s not. You also shouldn’t bill anything until it is signed.
Dr.Bethany Fishbein: That’s kind of a mindset shift because I think most I don’t know a lot of doctors see the signing of the chart as indicating, “I saw the patient.” Right? Especially in a multidoctor practice. When I signed a chart, it means I saw them instead of my husband or somebody else. And always that’s it. So I think shifting that to the blurb that you said you know, “I attest that everything in here is correct, etc.” is a good mindset. What’s another common thing?
Dr. Viktoria Davis: Probably another common thing I see is for like documentation on special testing. Things like photography, OCTs, visual fields, and things like that. That documentation doesn’t have to be incredibly elaborate. But it does need to include more than just, “Testing was normal.” or “Testing was unchanged.” or things like that, you know? And that’s something that I see a lot, is that that documentation on that special testing is very limited at best. For any special testing that’s done, you need to have clearly in the chart the reason why it was done and why that specific special testing was done so far. In other words, if you have a patient with, you know, glaucoma. “Okay, you want to do an OCT, you know optic nerve head, or CT. Then your reason for testing would be primary open angle glaucoma, monitor progression, and guide treatment. That’s the reason why you’re doing that. It’s not just because they have glaucoma. It’s because you are monitoring the progression of their glaucoma and guiding their treatment. And then you also need to state the results of it. So what things look like. Most of our testing that we do has some numerical values that are associated with it. It’s always an easy thing to put those numerical values in. Some EHRs will let, you know, and automatically import those numerical values from your instruments and things like that. And that’s totally fine. Otherwise, even just a brief analysis of what it is, you know, what the results of it were? And then any comparison to previous. Insurance companies love to see, you know. That again, that monitor progression and guide treatment. They want to know if things have changed. And that’s what we’re looking for. So basically it is just documenting what your brain is thinking. You know what you’re looking for when you do this. And then in that case saying, “No change from previous as your comparison is probably sufficient if you’ve stated what your results are also. And then also your recommendations. So what are you going to do about it? What happened? What are your results from this? And that could be continued Latanoprost, one drop of qHS, return three months or whatever. But why do you want this test? What is it going to do to help you? What the results of it were? What changes you saw? and what you’re going to do from it. And that’s really what needs to be documented. Like I say, this does not have to be a huge multi-page thing. This doesn’t even have to be really a multi-sentence kind of thing. One thing which I think can help all of us as optometrists now is the fact that almost every general practice healthcare these days have patient portals. And anybody who’s ever had any imaging or scans done whether that be you know, an x-ray on a broken bone or whether that be, you know? A routine mammogram or things like that. You can look on your patient portal and see what that radiologists report looks like. That’s very similar to what our special testing reports need to look like. It’s the same guidelines there’s nothing which is different for optometry as opposed to anything else. And they’re going to do the same things there. You know, as far as what they’re saying, Why did you have to have this done? What did you find? If there was a comparison to the previous, what any changes were and what they’re going to do about it? And that’s like I say exactly the same things that they’re presenting in their reports or things that we’re presenting in our reports as well. And that lack of documentation on those special testing is fairly rampant in optometry.
Dr.Bethany Fishbein: Yeah, I imagined that to be so. Before we close here, give an example of some of the crazy ones. Of things that you don’t see too often but you’ve seen once or twice that really could have gotten this doctor in trouble.
Dr. Viktoria Davis: So one of them and this kind of again, goes back to EHR documentation. And this is kind of talking about what I mentioned earlier, internal inconsistency in charts. I have no idea how this doctor’s EHR was set up. But somehow, the same test was recorded multiple times in an encounter once as normal and once as a problem. So basically, the doctor would go through and push the normal button and normalize the chart. And then if there were wrong things, then he’d go back and change those. So the same test was in the charts that I was auditing multiple times with different results.
Dr.Bethany Fishbein: I mean, that can’t be right, no matter which way it goes. Because it can’t be both?
Dr. Viktoria Davis: Exactly . It can’t be both right. It can’t be both. I mean, even down to things like CD ratios being recorded differently in two different spots in the chart. And I had a really, really hard time doing this audit because I couldn’t figure out why it was done. And like I say, when I’m doing a friendly audit, in particular, I’m always trying to give the doctor the benefit of the doubt and say, “Okay, it looks like this and you know, kind of trying to get inside their brain a little bit and I literally could not tell what was done. And most auditors at that point would have just thrown in the towel and said, “I can’t figure this out and so they don’t deserve any money.”
Dr.Bethany Fishbein: Yeah, so there’s an advantage of having a friendly auditor.
Dr. Viktoria Davis: Definitely. So and then the other. This is one that I heard of. I did not personally see this, so I can’t actually vouch for it, but I heard it from the doctor who was doing it and I mentioned this actually on the other podcast that I did with you. With a doctor who was really trying to work the system for insurance. And so for special testing codes, which are either unilateral or bilateral, some macular or binocular, or things like OCTs and visual fields and stuff like that. He would have the patient in one day to do one eye. And then like a few weeks later to do the other eye. And bill for both of those. And there’s a lot of reasons why.
Dr. Bethany Fishbein: He billed twice?
Dr. Viktoria Davis: Yes.
Dr. Bethany Fishbein: And an office visit for each?
Dr. Viktoria Davis: I don’t know for sure whether they billed an office visit for each if you’re doing just a standalone visit. Like all you’re doing is a field then, you know if you’re not spending any time with the doctor and it’s just with the technician then typically there’s not an office call that’s billed along with that. But yeah, he’d be like, “Oh yeah, they came in to get their glasses adjusted and so we just stuck them in for an OCT on one eye and then billed for it.
Dr.Bethany Fishbein: That crosses the line from, “Oopsie. I hit the copy Forward button.” to “I figured out a loophole and want to get paid for two fields every time I do one instead of one.”
Dr. Viktoria Davis: Exactly.
Dr. Bethany Fishbein: But I mean that exists out there. Somebody’s looking for the loopholes is probably not going to be the conscientious one saying, “I’d like a friendly audit.” They know, right? That they probably wouldn’t pass and are just taking their chances.
Dr. Viktoria Davis: Right? Correct.
Dr. Bethany Fishbein: Okay.
Dr. Viktoria Davis: The much more common thing that I see and this isn’t necessarily something that’ll, you know, get you in trouble. But it’s just something which is not the smartest thing to do from a billing standpoint or bottom line standpoint, is the doctor who is so afraid of an audit that they just downcode everything, you know? For example, they’ll say, “Oh, well, optometrists. I’ve heard that they never should bill a level five. So just to be safe. I’m gonna bill level three on everything. And, you know, insurance companies don’t like that either. They really want you to bill properly, you know, and appropriately. So even though you know, they aren’t just out to get you. And I don’t think insurance companies for the most part are out to get you. Some of them may want to bleed you dry but that gets into a whole different issue. But, you know, they want you to bill properly and appropriately and bill based on what you actually did and what’s in your chart.
Dr.Bethany Fishbein: Yeah. I know that. That certainly comes up I remember you did a webinar for our Power Practice clients on “Don’t Fear the Four” and it was all about level four offices and codes. And that was really the feedback that we got afterward. It was a lot of people saying, “Wait, I’m doing this and I’m coding. I’m coding for level three because I was afraid.” And that fear can be depending on the company, a $30, $40,or $50 encounter. So learning that and getting over that fear is important. Okay.
Dr. Viktoria Davis: Yes. And one other thing I wanted to mention here. Also when we’re talking about the process of an audit and what happens if you do get audited and when you do get that letter. There frequently, almost always, there is an opportunity for you to appeal the audit or to explain your charts in your auditing. You know, explain your side of the story. And that is always something that I encourage doctors to do. Again, if they believe in their coding and if they believe their charts are correct, then, by all means, explain it. There’s no reason just to take what they say just because they’re a big company or something like that.
Dr.Bethany Fishbein: That explanation, does that go with, “Okay, we’re just requesting 10 charts.” They might have just been your random turn or do you appeal when they say, “Three of these charts you didn’t have appropriate documentation for the code and we want $14,000.” Like when do you appeal? Or is it if they request those charts and then you look and you realize you didn’t sign them? And you copied forward and you have inconsistent findings, etcetera, etcetera, etcetera? And you think, “Okay, I’m gonna fail this.”
Dr. Viktoria Davis: Don’t give them more information than they asked for. That’s another kind of big thing is that you know, give them exactly what they asked for and only what they asked for. So don’t volunteer information, you know. Even if you looked at the charts and you’re like, “Oh my gosh! I totally messed this up should I say something?” No. Let them look at it first. And if they say that something’s wrong, you know, then follow up with that.
Dr.Bethany Fishbein: Gotcha. All right, Viktoria. Thank you. You have the unique ability to make insurance interesting and give good advice and solid things that people should know and really feel doable if you just pay attention to them. If somebody wants to find out more, or is interested in getting a Power Audit, where do they go for information?
Dr. Viktoria Davis: They really can go to the Power Practice website, which is www.powerpractice.com. And there is a tab there that talks about the Power Audit and that’s really where more information is. There are also email addresses on there as well and we’ll come to shoot off an email and somebody will get back to you.
Dr.Bethany Fishbein: Awesome. Thank you so much for taking the time once again and sharing all of this useful information. To take something that sounds really scary and makes you realize it doesn’t have to be as long as you’re doing what you’re supposed to. So thank you so much. Thank you for listening.
Dr. Viktoria Davis: Thank you. I enjoyed it.