How to Avoid an Optometry Insurance Audit & What To Do If You Are Audited
By: Kayla Groves, PECAA Billing & Coding Advisor

Regardless of your specialty, an insurance audit is the absolute worst nightmare of any physician. They are tedious, time consuming, and flat out intimidating. Many optometrists have falsely come to the belief that because they see fewer patients and perform fewer high dollar procedures that they are exempt from audits. This could not be further from the truth. In fact, optometry is rapidly moving up the list of CMS’s Comprehensive Error Rate Testing ranking of the most fraudulent and abusive medical specialties.

What Is An Audit?

There are two main types of audits: target audits and random audits. Target audits are the kind that proper billing and coding can help you avoid. These occur when your billing pattern changes or becomes irregular, therefore sending red flags to insurance companies. This can include volume of patients being seen, repetitive services, extensive billing for diagnostic testing, and billing for services that are not common within optometry. Random audits cannot be avoided, as they are randomly chosen by insurance companies. Every provider is likely to experience at least one every few years, depending on how many carriers you are contracted with. These typically are more “mini-audits” and will consist of only a few patients, although they could be extensive.

Things to Avoid to Help Prevent An Audit

Level four and level five visits are the most common way to attract an audit. This includes using both the 92xxx codes for General Ophthalmological Service and the 99xxx codes for Evaluation and Management. This does not mean do not bill for them if you actually perform a level four or five exam, it just means be prepared with all the proper documentation to back up why you coded the level so high. Billing for diagnostic testing without proof of medical necessity will also get you flagged for audit. Make sure you are using proper diagnosis codes and modifiers on all diagnostic testing claims; this will also help you avoid claim denial. Repetitive or “confirmatory” testing is not considered medically necessary, so make sure you aren’t falling into a pattern of “panel testing”.  Panel testing is having a set list of diagnostic tests you perform solely based on a chief complaint. You need to also ensure you are not just using the same codes for every exam you perform, as repetitive coding can get you audited as well.

It is important to remember that not all red flags can be avoided. If your practice sees a higher concentration of geriatric patients or patients with ocular disease, you will obviously perform more testing than a provider that does not. Just keep in mind that this will make you more susceptible to an audit, so keep your medical records in tip top shape!

You’ve Been Audited. Now What?

First and foremost, stay calm! Yes, audits can seem like the end of the world, but I promise they aren’t. Once you receive that pesky little letter, go over it carefully. Your letter should contain a detailed description of everything they are looking for. Most audits will request records on 10-20 patients for certain dates of service, although some can be much more extensive and request 100 or even more. A good course of action is to assign one person to handle the audit, as multiple people working on one request can lead to errors and/or missed charts.

Once you have gathered all of the records and submitted them, it is important to remember that your auditor is likely in no hurry. Audits can take weeks or even months, and your practice is not the only one your auditor is working on. Be sure to designate one contact person in your office so that your auditor has a direct point of contact for anything they need or follow up questions they may have. Should that point of contact need to change for any reason, notifying your auditor immediately will ultimately speed up your process and make it easier for everyone.

Audits are no one’s favorite thing, but they are a necessary part of medical billing. Try to remember that while they are regulating you, they are also regulating everyone else. This in turn leads to better care for your patients, which is all of our number one goal.


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