Podcast: Approach Post-Audit Education Like a Pro

In this episode of compliance conversations, I sat down with Stephani Scott, VP of Audit Services for Healthicity, to chat about her twenty years of experience and pick her brain on important auditing issues.

As all of you know, auditing is a crucial component of an effective compliance program.

Stephani explains how auditors should approach post-audit education with difficult providers, “Be prepared, first and foremost.” Then she adds, “Make sure you’ve reviewed the audit and you know where the providers did well. Sometimes the effectiveness depends on your approach.” Scott provides rules for post-audit education, including, how to deal with unique challenges, like:

• A physician who inherently distrusts auditors, “some providers have had really bad experiences or there might have been an error in the past.”
• Why you should avoid pronouns, “never say, YOU did something wrong.”
• How to get providers to really hear you.

Tune into my latest episode of Compliance Conversations: Essential Steps to Post-Audit Education (That Actually Works), to learn the auditing ropes with expert, Stephani Scott.

In this episode, Scott is going to teach you how to approach post-audit education like a pro. You’ll learn how to build trust with providers, change behaviors so you can finally get the results that you need, and she’ll also cover the best way to deal with providers who are bad apples, the very rare and few who code fraudulently and incorrectly on purpose.

Episode Transcript

CJ: Welcome everybody, this is CJ Wolf, Healthicity's Sr. Compliance Executive, and welcome to another episode of Compliance Conversations. Today we have a wonderful guest, Stephani Scott. Welcome, Stephani.

Stephani: Thank you for having me, CJ.

CJ: Glad to have you here. Stephani is Healthicity's Vice President of Audit Services and she's got great expertise, great teams that she works with, and a lot of exposure across the country and we thought it would be a great idea to kind of pick her brain a little bit about what's new, or what's going on, or what are the main issues. Sometimes they're not new right, sometimes it's the same issue over and over.

Stephani: That's right.

CJ: It's worth repeating when that's the case. Stephani, before we get started with some of my questions I was wondering if you'd let our listeners know a little bit about you. What's your work experience been, what have you done, who have you worked for and those types of things.

Stephani: Sure, happy to do that. I've been in the healthcare arena for 20 plus years, and I've had the opportunity to work in a lot of different locations. I've done long term care, hospital, multi-specialty practice physician groups. I've also worked for a major AMR vendor, so it's been nice to have that background at the different locations. All of those I've primarily done health information management or pro-fee coding and documentation services.

CJ: So, credential-wise, I think you have that AHIMA credentials as well as some coding credentialing.

Stephani: That is correct.

CJ: What are those credentials?

Stephani: I have an RHIT and a CPC.

CJ: Great, well very good, and you lead a team here at Healthicity. Can you tell us a little bit about the team you lead and just maybe a high-level overview of what you guys do?

Stephani: Sure, we do a lot of coding and documentation audits. We do risk adjustment audits. We do production coding as well. We've got a team here in the Salt Lake office, and many of our team members are cross-country. So, we have a very diverse team. That is kind of challenging. They have different time zones and times that they work. It's kind of to our benefit because our customers are across the countries as well, and we're able to pair up a team for each of our customers.

CJ: Yeah, and what I love about the folks that you interact with on your team is, let's say, a client has specific needs for a very specific specialty, you can usually find anybody that has expertise in that specialty, right?

Stephani: That's right, because we also back-fill our team with contract support as well. So, if one of my team members doesn't have that particular skillset, or they are pulled off on another project, we have access to other AAPC members with those credentials that we'll pull in.

CJ: Yeah, and I think that's important. When I was a Billing Compliance Director, a lot of our on-staff folks new how to do E/M coding and some of those kind of routine type of things, but what if you had otolaryngology oncology, a very specific type of specialty. You guys can usually find somebody that has that experience.

Stephani: That's right.

CJ: So that's really great. So, some of the questions I wanted to ask Stephani to have to deal with the fact that she has clients all over the country, so not only does she have expertise in coding and auditing, but you kind of see trends. And when I was working and I was just in my bubble of my institution, I had a lot of knowledge of my institution but I didn't always know the ins and out of what my peers were doing, so I think you guys have an advantage there. You see maybe from academic center from academic medical center you see what the differences are and what the trends are and that sort of thing.

Stephani: That's right, and it's interesting that you say that, CJ, because I was just recently asked that question as, "What are some of the new trends we're seeing with auditing?" And they're kind of the same old things, to be quite honest.

CJ: Okay.

Stephani: Doctors are missing the family history or the review of systems or medical decision making. There're differences in those areas, but where we're seeing changes or differences in the types of audits that folks are performing, I mean, most folks are beyond the baseline, let's just do a straight E/M random sampling auditing. They're doing more at-risk audits, they are identifying as an organization where the risks are, is it higher dollar or is it high volume for a specific service or code, that sort of thing.

CJ: Or maybe a government agency has put it on work plan, and so rather than, I guess, I always thought, that kind of those baseline audits are good, but after you've done one or two of those, it's really good to focus in on those risk areas, and be able to say "you know what, we've thought a little bit more on this and we really want to focus on these kinds of services.".

Stephani: Well especially if you've got a seasoned audit compliance plan, and your providers. You've seen that incremental improvement, so now where do you go?

CJ: What do you do next?

Stephani: You do your at-risk audits.

CJ: Exactly, well good. Well when you're doing some of those audits and you've got a team of auditors, you know, what do you recommend and what do you deliver post audit education to, let's say, a difficult provider? I've worked in that field where we've had doctors that are difficult, even nurses, whoever the provider may be. How do you deal with that, how do you recommend your auditors do it, as well as maybe other auditors that are in house?

Stephani: Gosh, that's kind of a loaded question. I always tell my staff when they come to me and say, "Hey I know this is going to be a really hard delivery of audit education for this provider, what do I do?" Well, first and foremost you've got to make sure you're prepared. Make sure you review the audit, make sure you know where those opportunities are, and where they did well. And because, sometimes, it's about your approach of, "Gosh I know this Dr.'s going to be hard to talk to…" so approach it lightly from the beginning, not from an attack. "So, this is where you did really good on your audit…" and then slide into maybe some of those opportunities.

CJ: I like what you said about being prepared. I oversaw a team of coding auditors at one point in my career, and I would always tell them "Those Dr.'s, if you make mistakes, and if your presenting to them mistakes, they are going to pick up on that, and then they are just not going to listen or trust, and that makes it more difficult when you already have a difficult message to deliver. So be prepared. Make sure your audit is squeaky clean, right, that you've got your backup, you've done it right, you're confident in what you're going to present.

Stephani: That's exactly right. Because if you do find a mistake after the whole audit's gone through, the auditor, the review, and the educator is going in and they look at a note and perhaps have a different perspective on what they are seeing, change it before you get there. Let them know that hey, you looked at it again, and they are going to have more respect for you if you let them know "Hey I went ahead and made a correction."

CJ: Well I like what you said, and it assumes some things. You said the "reviewer," so the auditor has done it and our reviewer has done it. I don't know if a lot of our listeners exercise that and practice that, some of them might just do the audit and present the results, but you should have some sort of review process so that you have another set of eyes looking at it if possible. Or maybe even just a portion of them, so that you're getting some QA.

Stephani: Yeah, we have that as a standard process in audit services.

CJ: Great. Well, cool. Now what about, what if the physician doesn't trust the auditor? What does the auditor do? That's kind of hard.

Stephani: It is, especially if another auditor has come in before this situation.

CJ: They don't trust the profession! It might not be the person, they don't trust the profession.

Stephani: Right, maybe they've gotten some bad information in the past or inconsistent information, so they are not going to trust the coder, they are not going to trust the auditor. That's a little challenging, again, you've got to look at the results of the audit before hand and decide "Okay, where is the biggest opportunity where I can make a difference in helping this physician." And when you go in, you should never use pronouns "your documentation", "you did not do x, y, z".

CJ: It makes it very personal, doesn't it?

Stephani: It does, and you want to kind of take that away, and perhaps say, "Gosh, in reviewing your note I didn't see the past family history, let's look at that together." Or ask the Dr. "Okay, this note the level of medical decision making didn't support what was reported but help me understand from a clinical perspective…" so now suddenly.

CJ: You're making an invitation to teach you a little bit, but you're getting your message across.

Stephani: That's exactly right. So now all of a sudden, the approach is completely different, and they are like, "Oh, they are here for me to teach them."

CJ: And you can still get your message across and he can say, "Well, I did this, this and this." And you go, "Well that's great, I didn't see. It sounds like you may have done that in your head and you did the work and the mental thinking, but I didn't see it here in the documentation. Can you show me where it is?" "Oh, I don't see it either. Well yeah, that's kind of why the guidelines say this needs to be a level 3 instead of a level 4."

Stephani: That's exactly right. And a lot of those physicians, too, like I just had a scenario last week where one of my auditors-we had been reported that they had been doing training with this physician-and this physician had been on the re-audit schedule multiple times because he just wasn't passing his audit. So finally, the trainer just put the paperwork down and said, "Okay, I'm never seeing past family history being documented." And he said, "Well, I ask the patient." And she said, "Well, walk me through the steps that you're doing." And come to find out this was a cardiologist and the question of family history of cardiovascular disease, the button on the E-mark template was right there on the left side of the screen for yes, but he couldn't see the button for No.

CJ: Ohhhh. So, when it was a no he wasn't finding it so it didn't get documented in the EMR.

Stephani: That's exactly right, and she said, "Wait a minute, just scroll over a little bit, let me see what else is on that page." And there it was, clear far over on the left, he just didn't know it was there.

CJ: Yeah, he knew he was asking it, and that he reviewed it, it just didn't get to paper, or electronic.

Stephani: Right, so they quickly pulled in the manager, and apparently, they were able to get someone to change it on the template, so he can document that now. So, think about, now the trust the physicians going to have because you took that extra time.

CJ: Yeah, you know, I've found that to be true as well, is that if you assume good intent, 9 times out of 10, you're going to end up helping somebody. If somebody has that malintent I guess you'll eventually find it, and it's probably not the auditor that is going to be the heavy in that case anyway, it's going to be elevated up. If you're assuming good intent, most of the time you're going to have a good learning experience and instill that trust like you were saying. And that's important, because the docs won't listen to you if they don't trust you.

Stephani: That's right.

CJ: Okay, how about . . . do you have your auditors, do you recommend kind of different approaches depending on the providers score? So, if they scored well or poorly are there different approaches you do?

Stephani: I do. I recommend to them, let's take a provider that has had a baseline audit. So, your approach with that provider, that first meeting, is going to be first a foremost to build a relationship and build that trust initially. So, you're never going to get through the laundry list of opportunities. So, you've got to introduce yourself, get acquainted, build some trust right off, and pick the biggest one or two things, opportunities, that then you can help that provider to improve upon, or educate that provider on. And have additional documentation there, little hand outs or something, for that provider. The next time you can compliment on that he or she did better, or didn't, or what went wrong, or what else you can look at. So, each time you're building with that physician and getting them to change their behavior if need be.

CJ: Yeah, and maybe not start with the nit-picky stuff, right? It's like, look, if I did 10 encounters and 5 out of 10 were missing part of review of systems you can kill that one bird with one stone and you get 5 out of 10.

Stephani: Yeah, I must tell you an example that just happened last week to me. We perform regular compliance audits for a group, and then their staff do the education. Well I had the manager give me a call, and there was a provider where it just went terribly wrong and the provider ended up stomping out of the room, and they asked us, "Hey, would you kind of come in and do the post-audit education for this provider?" And I asked, "Well, what happened?" And this provider was known to be challenging, the overall score wasn't too bad, I think it was 80%. So out of 10 records that wasn't too bad, but the approach was immediately, "Well, you didn't document the chief complaint." But it could be inferred in the record. So right off the bat the physician…"

CJ: Was kind of, put up defenses.

Stephani: Right, because it was, "You didn't document the chief complaint.".

CJ: Right, you know, I liked what you said about that earlier, about not using those pronouns, saying that "I couldn't find a chief complaint." Because sometimes you don't know. Maybe they set up a system where the nurse is supposed to document that chief complaint or document parts of the history that are acceptable, right? So, you don't want to be accusatory, you don't want to accuse people.

Stephani: Right, well come to find out, the note was down at the bottom. So, the physician portion was documented clear down at the bottom of the note, but before they could even get there the physician was on the defensive. The trainer had lost the opportunity for education by that point, and then the physician wasn't willing to continue the conversation. So, it's all kind of about that approach.

CJ: Interesting, do you think that happens because the person, in this scenario, the person that was education was not the person that was doing the audit, they just took someone else's audit results, or does that not make a difference?

Stephani: I think that in this case, the auditor, well the manager told me that the auditor knew that this physician was going to be difficult, and was very nervous, and was just going through the laundry list of opportunity, rather than selecting the items that really could make a difference.

CJ: So, it was that anticipation that can make you nervous and you shoot yourself in the foot.

Stephani: So, they've got to go back and rebuild that trust before they can have a successful post-audit education with that provider.

CJ: So, we kind of talked about some of the things like if there is an obvious piece of the encounter missing, what about if it is kind of close? How do you address audit results when there is maybe one over coded ENM level, or one under coded? And sometimes those are black and white, or sometimes they are kind of gray. So as the doc or the provider is getting close to what it should be, how do you deal with those types of results?

Stephani: Again, we're not clinicians, so I always like to do it as an education for me, so that I can learn as an auditor. So, I like to find out from the physician, "So tell me what you were thinking, why did you think this was a higher medical decision making? Help me understand what cognitive thought process went into that, perhaps to make it over?" because if you've got one over one under, it sounds like that provider is probably doing it correctly most of the time, it's just these subjective cases, these one-off patients right? So, I try to make it an educational opportunity for me, and then we can guide into that specific patient to see if there was additional opportunity or not.

CJ: I think that's a good approach, because docs I think in general, they may be kind of strong willed, but if they are approached in a way, kind of like you're saying, teach me a little bit. They usually open up. Even if you do know it, you are kind of stroking their ego a little bit, and who cares, because if it gets you through what you're trying to accomplish, then so be it, and they can sometimes open up and like you said you learn something.

Stephani: That's right, and who knows, maybe it's an EMR issue, "Well I actually talked to that about the patient but there was no where to click it".

CJ: And then you saw that you've come full circle and now you're building trust with the provider. Well what about those providers, and I think they are few, maybe your experience is different, but there are some that are just bad apples. You got some of those? What do you do there

Stephani: Sure. Sure.

CJ: And I'm not trying to paint a broad brush, but in any profession, there are people that don't do what they are supposed to do.

Stephani: That's right. Especially if the provider has someone else doing part of the coding for them in the background, a lot of them will view it's a waste of their time, and I've certainly had my fair share of providers that have kind of been, quote, bad apples, and you've got to just be prepared. Make sure they understand you are there to help. You are not there to criticize, you're not there to give them a score card, you're just there to help. Then pick your battles. Pick the one or two opportunities that you want to talk about and leave the others.

CJ: Sometimes, I've just had to, with some that are just defiant, and they will have nothing to do with the report, they will say therefore healthcare is so poor now, and this is why we're all going to where in a hand basket, and it's just the world is ruined. Sometimes I just had to say "Look, I didn't make these rules up. I didn't sit around on a weekend." Because sometimes they attack you personally. And I just had to say "Look, I didn't make this up, these are what the rules are, they are what they are, your organizations policy is this, there are ways to address that, I'm not the one that can really address those types of issues. I want to make sure you understand the results here, I want to make sure I didn't miss anything, and I want to pass these results onto the appropriate party and they will deal with it." Sometimes you just have to kind of hold your ground, and tell them this is what it is, and if your organization is going to follow through on their policies than they will do what they are going to do. You're not necessarily the executioner. So, let me ask you something else. What are the trends you're seeing, or are they kind of the same old things, if you had to pick, because you guys get exposure across the country in all different settings? What would you say the two or three biggest things are, in general, that providers could work on?

Stephani: We see that with hospital initial visits that they are not getting the family history. When mom and grandma is 103 years old, clinically is that patient's family history medically necessary, or even make a difference at this point of time with that patient? I mean, I get that from physicians all the time, and I understand that. But like you just said, the documentation guidelines require those elements. I always like to discuss with physicians, okay, let's make it easy, what's in your mind, why did this patient present, and what would be relevant? You don't need to go through a full family history.

CJ: In that example what is something they might say, that you've heard them say?

Stephani: Heart disease, dementia, things like that.

CJ: So, something quick and easy so that you can count that.

Stephani: Right. So, we still see a lot of opportunity there, same with review of systems. Something that has kind of been coming up the last several years that I've been auditing is this language in the EMR's that a 12-point review of system is document, or a 10-point review of system is documented.

CJ: Well then where is it?

Stephani: Which systems?

CJ: Which 12? Where is it?

Stephani: Right, and so, the argument is "well, that's the same as saying all other systems are negative." Well, it's not quite the same, it has a little bit of a different meaning, but we're seeing that pop up, and I don't know if it's an EMR thing, or a terminology where they are clicking something where they think all others are negative and that's the statement on the output, I don't know.

CJ: Yeah, because when I was doing this on a day to day basis we would teach doc's, "look, mention a few pertinent positives and negatives that apply to the HPI, and then say all others negative if you did all of them." And I'm not telling people to lie, but if they did all the others, and is that still valid to give you a full review of systems.

Stephani: Yeah.

CJ: Good that hasn't changed.

Stephani: No, it's just that wording.

CJ: Yeah, but it's saying the right words in a way.

Stephani: That's right, That's right. And then there is medical decision making, that's always so subjective, particularly for auditors.

CJ: Yeah, that can be a hard one. I remember one where, the scenario was, because a lot of people think that this certain chief complaint can never be a level 4 or 5. I always gave the example of a headache, well, some headaches, chief complaint headache patient 1, chief complaint headache patient 2. Chief complaint headache. Well in patient one the headache always starts on Monday morning, gets worse around 5 o'clock in the afternoon, when they get home their spouse rubs their neck the headache goes away. They never get the headache on vacation, they never get the headache on the weekend. It's probably a stress headache, it's probably not a high level medical decision making. That's patient one, but patient two with the same chief complaint of headache, if the patient has polymyalgia rheumatica, which is PMR, they have an elevated set rate, and they had vision changes in one eye, and they have pain just over the temple, but their chief complaint was still headache. Well that could be temporal arteritis, left untreated can cause blindness. So, your medical decision making could be so different. So, what do you tell people that a chief complaint of headache could never be a level 5, or whatever the chief complaint is.

Stephani: There is not a one size fits all here. Every patient is going to be different.

CJ: And that medical decision making, like you said, in the scenario I just described, it just depends.

Stephani: Absolutely.

CJ: It depends on their history, and what contributing factors there are, because medically that headache could indicate something much more significant in one patient than another.

Stephani: Well even if you say patient one, if they said, "This is the worst headache ever.", that's a complete different medical decision making.

CJ: Or, "It woke me up in the night" vs the scenario that I just described where "Yeah, it's just kind of dull, it's a 2 on a scale of 1 to 10, and only when I work, or when I'm babysitting the kids". Yeah, medical decision making, I'm not sure there ever is an easy way. Now one last question, we're kind of getting close to the end of our time. Any thoughts on the difference of medical decision making and medical necessity, because you know, medical decision-making is kind of a, there's somewhat of a formula in the guidelines to help you get points and that sort of thing, where whether it was medically necessary to begin with is not always in the ENM guidelines, right? That's more of a medical determination, and you're not necessarily doing that when you're auditing a code, right?

Stephani: That's right, I have a good example for that scenario. I was auditing a physician and the client submitted 20 dates of service, and I had 2 patients where the submitted anywhere between 3 to 5 sequential dates of service. So, this patient had a problem with their toe with a lot of pain, 2 days later was seen again, and it ended up being cellulitis, and then it progressed, and they decided the patient had gout, well the Dr. was documenting a comp history and comp exam for all 5 visits, even though it took place over a 2-week period. But the medical decision making, although it was getting worse, he was only addressing one problem. So, this organization and their Medicare MAC carrier allows for you not to require MDM as 2 out of 3 key components, and that's how the provider was coding, based on history and exam.

CJ: Gotcha, on those subsequent visits.

Stephani: Right. Well I down coded those subsequent visits because of the nature of the presenting problem. Didn't appear that it was medically necessary to capture a comp history, and comp exam, for those subsequent visits.

CJ: Good point, and I think you pointed out an important part, looking at your MAC and really reading their newsletters and their education and guidance to get a sense of if they require that or not as a key component.

Stephani: Typically, when you're just having one insight into one visit it's hard to say if it's medically necessary, but to me this was fairly clear, because I had those 5 visits in a row, and it was not medically necessary.

CJ: Right, it was kind of dealing with one issue over multiple days.

Stephani: That's right.

CJ: Interesting example. That's kind of what makes it fun, right? You get a lot of the same kinds of scenarios, but you get some that are just unique and different, makes it interesting.

Stephani: That's right, I love being an auditor.

CJ: Good, well that is a good thing for someone in your position. Well Stephani thank you so much for your time and your expertise, I really apricate your visit.

Stephani: Thank you for having me CJ.

CJ: All right. Well thank you everybody for listening, until next time, happy compliance.