is not very legible that's not a problem. Just make sure there's a legend that whatever that squiggle is that actually equals your name. My issue for audits is not one for doctors to necessarily be fearful but to take a proactive stance. The idea is when someone's looking at your records you have to think of why are they doing it? For the most part an insurance company is looking to see did they pay for a service that they feel they shouldn't have because the doctor, one, didn't do it, or that the doctor didn't document it properly, or finally if it just wasn't medically necessarily. In deference to dealing with these audits and dealing with making sure that you're prepared, the first thing would be in your office, make sure when the patient first comes in do you have proper history forms, do you have an examination format that allows you to make sure you hit every step of your exam and that it's all documented. Remember that indicating something is normal or that is within normal limits still must be documented. If it's not documented as such it's not assumed. Always make sure that's there as well. When you set up a treatment plan give short term and long term goals. Make sure that someone who's reading the chart besides yourself can see the patient improving. Clearly audits are going to be more frequent in my opinion simply for this reason. Due to some of the changes with healthcare that we all see going on with the Affordable Care Act insurance companies arm is readily available to raise rates as they once have. As a consequence what are they looking to do in my opinion? Always squeeze the provider to see whether or not the services you provided were done. Now, are they going to look at every provider? Absolutely not. They do not have the time nor do they have the resources, but they are going to look for providers that do high level of services. I will say to you do not worry that you do a high level of service. I'm okay with that. Document it. Make sure that it's reasonable. There are certainly going to be times for you to do more services than others. If you have a practice that deals with patients that have more severe conditions there is nothing wrong with you doing more services than the doctor that deals with something simpler. Just make sure that every service that you provided is done. If you do that I think you won’t have much trouble. I've done enough expert testimony on cases like this and the one thing that comes up for sure is that if it's in the file, we win. If it's not in the file, we can't win. We can't make it up later, so start getting in the habit now
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