Do You Worry About Getting Audited?

Just thinking about getting audited puts some practice owners in a state of panic.

  • Why would someone audit me?
  • What could they be looking for?
  • What if they find something?
  • What if I made a mistake?
  • What could happen to my practice?
  • How can I prepare for an audit?

These might be just some of the thoughts that worry them.

So… best to meet the medical audit monster head-on and look it squarely in the eye.

Because things we’re not familiar with tend to intimidate and scare us.

But, once we have even a basic understanding, what once was scary no longer is.

So, let’s talk about “audits.” Let’s start by looking at…

What is an audit?

As you probably know, an audit is an official process of inspecting an organization’s financial records, processes, operations, and compliance. They may be performed both internally and externally.

The objectives of an audit are determined by the type of organization being audited and the industry it belongs to.

In general, the overarching goal of an audit is to ensure that the organization in question is performing as expected, complying with all applicable standards and laws.

In general, audits in business and healthcare are not uncommon. All types of organizations conduct them, including:

  • Accounting firms
  • Government and State agencies
  • Insurance Companies
  • And, of course, the IRS

Medical Practice Audits

So now, let’s talk about medical practice audits: what’s unique about them and what you need to know.

Heads up, though…

If you are listening to this before July 20th, 2023, you’ll have time to get on a webinar with NPBO and Susan Montana, who, among other things, is a Certified Medical Practice auditor.

Now here’s what’s important about audits…

They are not just for business owners. All clinicians need to be aware of the auditing process.

As an employee, you may find yourself part of one or many audits. That audit may be directed toward the practice or the individual clinicians. So this truly is for all of us with licenses.

Audits can be internal and done proactively, or they can be external. They could be used as a routine check, or they could be the result of a concern or complaint.

But first, what is a medical audit to begin with?

A medical audit is a process that can help determine if a practice follows the standards that various government and professional agencies set forth.

So basically…are you doing everything you should be doing, not only in the types of care you are providing but also in the business aspect of your practice?

Several state and federal programs may do an audit of your practice, including, but not limited to the:

  • CMS – Centers for Medicare and Medicaid
  • OCR – Office of Civil Rights
  • OIG – Office of the Inspector General
  • OSHA – Occupational Safety & Health Administration
  • DEA – Drug Enforcement Administration
  • and IRS, to name a few.

Compliance Audits

What are the common types of compliance audits that may be done? These will vary somewhat, but here are three types of audits you may experience.

  1. Billing and coding audits. This is probably the first thing providers think of when they think of audits. For years, I’ve heard from providers (and was even taught this) that if you code higher than a 99213, you would be audited. They would say this with fear in their voices even if they were doing the work for a 99214 or even 99215. Not only did this idea come from providers, but from management as well.
  2. Clinical documentation audits. You may have experienced this from payers looking at patient medical records to verify that you did the work you said you would. But it’s not the only reason payers may look at clinical documentation. Are you providing quality care and in compliance with standards of care? Or are there liability issues? We all know our documentation can protect us or get us into trouble if it’s not there.
  3. Compliance audits usually focus on the federal and state regulations you should follow. Think data security, infection control, and privacy, to name a few.

Of course, within all of these is the idea of “Risk Management,” which will include aspects of legal, safety, and financial risks associated with the practice.

But these are only some types of audits you may face or even want to be faced with.

Audits do not necessarily have to be punitive. They can be educational and help you improve the quality of care you deliver and your business.

Would you rather listen?

Webinar Information:

But now, what about the webinar? On July 20, 2023, Susan Montana will discuss what to expect in an audit.

Susan Montana is a Certified Professional Medical Auditor who has been working with practices and clinicians for several years. She’s also a Certified Professional Coder and a Certified Healthcare Technology Specialist. You may know her if you were on an earlier webinar where she answered coding and reimbursement questions for the NPs.

The topic for the webinar is What to Expect in an Audit.During the webinar, Susan will discuss the following:

  • Who is auditing me, and why?
  • How to develop an audit response plan.
  • How to perform a self-audit prior to submission of any documentation.
  • What changes, if any, should I make immediately?

This webinar is something all NPs will want to attend! Think of it like this: “It’s not if you will be audited, but when.”

You can sign up for this free webinar at

Have you been audited? Share your experience with the NP community, and leave your comment below.

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