Identify your audit focus

A. Last month, we focused on individual claim audits as a part of self audits. This month, we will focus on extrapolation audits. Although an extrapolation audit can be considered a self audit, it is strongly recommended that it be conducted under attorney-client privilege and under the direction of a health care expert. Before conducting an extrapolation audit, you should put a lot of thought into deciding whether or not the audit is needed. This is your first and most important step.

Extrapolation audits are reserved for those occasions when you are confident that you have an issue or potential issue with a particular type of claim or claim error. An example of a type of claim error that might warrant an extrapolation audit would be one that is repetitive in nature (such as consistently missing data on CMNs) identified during your individual claim audits. Once you identify the type of error you need to focus on, look at the time period that is involved.

When doing an extrapolation audit, you should conduct the audit using a statistically valid sample. One of the most widely used samples is called RAT STATS. Information regarding RAT STATS can be found at http://oig.hhs.gov/organizations/oas/ratstats.asp.  This site will give you detailed instructions on how to prepare and conduct a statistically valid sample that is widely accepted by the government and government contractors.

Depending on your claims volume, the time period involved and the type of error(s), the number of claims to be reviewed might be large. It may be necessary to collect medical records as a part of this review. If you involve outside parties such as physicians and hospitals, great care must be given to the potential public relations issues that may arise.

Tom Walters is the president of Total Office Management in Columbia, S.C. Tom can be reached at 803-920-0606 or totalofficemgmt@mindspring.com.