In the first part of this series, we began discussing how to sit down with your providers and review the results of a recent audit. Much of the time, physicians and other practitioners do not have extensive backgrounds in coding or billing, meaning that it will likely be necessary to explain not just what aspects could improve, but how and why these changes are necessary.

To start, make sure that both parties have a clear understanding of medical necessity. Seeing as medical necessity guides much of a patient’s encounter and treatment, both the providers and the rest of the staff need to have the same definition of what is and what isn’t necessary. If physicians are filling their notes with superfluous information or, even worse, failing to report a true aspect of medical necessity, then bringing this error to their attention and making sure everyone is on the same page is essential for the effectiveness of the practice.

When discussing both medical necessity and any other area, be sure to back up your words with facts from the audit itself. While many providers want things to run smoothly and will happily work to improve, some may argue against your findings and try to continue documenting in the same way. In these cases, make sure you have the results of the audit on hand so that you can reinforce your position with objective information.

Audits can be a valuable insight into the inner workings of your practice, but only if everyone is on the same page with how to improve. Sitting down to discuss finding with your providers might not be anyone’s favorite task, but it is crucial to making sure both sides know how to help the other. As long as everyone can explain their reasoning rationally and professionally, your practice should soon be able to make several changes for the better.