The Banner Health Plans (BHP) Compliance Department received approval from AHCCCS Inspector General to resume the provider audits effective June 15, 2022. Previously, the audits were suspended due to the Public Health Emergency from March 2020 to present. These audits are required by AHCCCS but are applied to all lines of business. This type of audit compares medical record documentation to the claims submitted and paid by BHP to ensure both are proper and accurate.
Progress notes not signed appropriately – Progress notes are required to be signed and dated by the rendering/treating provider after each appointment and/or procedure prior to being billed. What we see are notes that say pending; notes that are signed up to a year later; notes that are signed by someone on behalf of the provider or notes with no signature or date. These examples make the note invalid.
Services billed under the NPI of a provider who did not render the service for an AHCCCS service – For AHCCCS, providers are required to bill the claim under the NPI of the provider who rendered the service. Incident-to-services that are allowed under Medicare for Mid-levels to bill under a supervising physician is not allowed under AHCCCS. The PA and NP must be registered with AHCCCS and credentialed. If it is not billed under the rendering provider, the claim is null and void.
Upcoding of Evaluation and Management Services – Coding Guidelines require medical documentation to support the proper evaluation and management code billed. What we see in practice, is that the provider’s progress note does not support the level of service billed. Frequently, we are hearing that providers are using autofill and auto-prompts to facilitate and improve documentation, coding, and billing. If used inappropriately, these tools can suggest a higher billing code than the actual services furnished warrant.
If you have any questions regarding the errors and trends, please contact us by email at: [email protected].