Free Webinar: Practice Marketing Tips to Get New Patients Now

Lea Chatham April 30th, 2015

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Register Now5 Marketing Tips to Get New Patients Now
Wednesday, May 6, 2015
10:00 AM PT, 1:00 PM ET

Want to stay competitive?
Implement these online marketing tactics. Tweet this Kareo story

Most practices depend on word of mouth to get new patients, but the landscape of healthcare is changing, and to stay competitive you need to expand your reach.

According to Google, 77% patients use online search before booking an appointment. Plus, social media has become the online version of word of mouth. If you aren’t engaged in active pratice marketing online, you could be missing an opportunity to grow and reach new patients.

In this free webinar, practice marketing expert and blogger, John Lynn, will walk you through:

  1. Using your practice website for marketing
  2. Improving search engine optimization (SEO) to get found online
  3. Creating a practice blog to build your online presence
  4. Getting started with social media and online reputation management
  5. Implementing patient-engagement tools like online scheduling and text reminders

Register now to learn new ways to use your website and social media to reach new patients.

Register Now

About the Speaker

John Lynn is the Editor and Founder of the nationally renowned blog network John also co-founded two companies: and Plus, John is the Founder of 10 other blogs including the Pure TV Network and Vegas Startups. John’s 25+ blogs have published over 15,000 blog posts, garnered over 30 million views and had over 122,000 comments. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy and @ehrandhit and LinkedIn

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4 Software Tools Concierge Practices Need

Lea Chatham April 28th, 2015

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Tweet This Kareo StoryBy Charles “Drew” Settles

Most people agree that the current U.S. healthcare system could be improved. Costs are ballooning, regulatory pressure is increasing, and reimbursements from payers seem to be shrinking. Primary care physicians may have it the worst. Lower reimbursements are forcing many primary care practices to focus on quantity of care over quality of care. It’s little surprise then that primary care physicians are experimenting with a payment model that allows them to provide a higher quality of care to fewer patients: concierge medicine.

Concierge medicine is akin to membership in a private club. For a monthly or annual fee, supplemented by small co-pays, concierge doctors provide unlimited care to their patients. Most (but not all) concierge doctors accept no forms of insurance, instead relying on subscription fees to provide a steady source of income. As a result, concierge doctors aren’t concerned about Medicare/Medicaid reimbursement reductions, Meaningful Use incentives, or other health IT-related government mandates. They also don’t have to worry about medical billing problems like ‘upcoding’ or ‘revenue leakage.’ Because of this, it’s sometimes thought that concierge doctors have little need for health IT—but that couldn’t be further from the truth.

The vast majority of concierge physicians appear to be health IT evangelists. This is because using health IT systems—such as patient portals, electronic health records, or practice management software—allows them to extend their abilities and capture additional revenue. Furthermore, as concierge medicine evolves and more groups emerge, being able to exchange patient health information between different providers’ systems will be key, just as with conventional medical payment models.

Software Tools for Concierge Practices

  1. EHR+PM: Concierge primary care physicians require many of the same systems as conventional providers.Tweet this Kareo story
    A well-designed electronic health record platform and practice management system are essential to any modern medical practice. Concierge physicians still need to take notes, send lab orders, prescribe medication, and schedule appointments. And while a medical billing system is still important—some concierge doctors do take insurance after all—the ability to process payments for self-pay patients is absolutely critical.
  2. Patient Portal: While some conventional physicians question the use of a patient portal, most concierge doctors realize the value many patients place on digital services. Younger patients particularly expect to be able to schedule appointments, pay bills, and request prescription refills online. Patient portals can also reduce unnecessary visits. Secure patient-provider messaging allows new parents or heavy users of medical care to seek an electronic consultation without taking up space on the appointment schedule.
  3. Marketing & Customer Service: Though many physicians still consider direct marketing to be in poor taste, most concierge doctors realize that it’s a necessity. It’s typically far easier to retain a patient than to acquire a new one, so customer relationship management software is essential for concierge practices. This is particularly true for those who aren’t affiliated with a group or some other way of getting referrals.
  4. Telemedicine: One of the fastest growing health IT segments is telemedicine. Savvy concierge doctors can use telemedicine apps as both a marketing tool and as a potential additional revenue stream. Patients like telemedicine apps because they provide immediate, low-cost access to medical advice. Physicians like telemedicine apps because they help capture new patients and lost revenue from phone or patient portal-driven consultations.

Perhaps even more so than conventional physicians, the right technology is essential for concierge doctors. Tweet this Kareo story
Building a complementary, well-integrated software ecosystem can help recruit and retain patients so the practice can maintain the patient base needed to sustain this model.

Are you a concierge doctor? What software systems do you find essential to your practice? Let us know in the comments.

About the Author

charles settleCharles Settles is a product analyst at TechnologyAdvice. He covers topics related to healthcare IT, business intelligence, and other emerging technology. Connect with him onLinkedIn.

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Two Ways To Enhance Your Medical Career

Lea Chatham April 23rd, 2015

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Tweet this Kareo storyby Erin Kennedy, MCD, CMRW, CERW, CEMC, CPRW

Did you know that anybody can enhance their life, and thus their career, by improving some simple, basic skills? Once you have a handle on these skills, there’s no telling what can happen but you have to apply them consistently: everybody needs to learn how to learn and learn how to teach.

Learn How to Learn
Learning is essentially acknowledging that you don’t know everything and being open to expanding your horizons.Tweet this Kareo story


  • What are you reading? If you don’t read, start slow and it will get better quickly.
  • If you are always reading a novel, try reading some non-fiction regularly.
  • If you never do fiction, start with some short stories and work up.
  • Take a class in something that appeals and intimidates you.
  • Play games on  your phone or computer that are not in your comfort zone, like words for a math whiz and numbers for the linguist.
  • Learn how to use your hands or your body a different way, like dancing or knitting or soccer or anything fun.

I bet you thought I’d be telling you to work on a career skill, and that certainly is a good idea. But for many of us, we need to start developing the ability to learn first. When you start with what you like and stretch your mind a little bit, you are learning how to learn.

Learn How To Teach
Teaching is not being a windbag standing in front of suffering students and talking to hear themselves. Good teachers listen to their students and try to understand how they perceive things so the facts being communicated get through to the brain. A teacher needs to have a good grasp of the subject in order to explain it effectively.

  • Offer to explain something you are good at to a friend who wants to know how.
  • Show a newbie some tips about a skill you have.
  • Write instructions just to see if they make sense when you follow them.
  • Improve your writing skills so you can communicate better.
  • Rewrite things that are confusing to make the meaning clearer.
  • Research the styles of learning and figure out how to explain to each style.

The truth is that we all teach, whether we realize it or not. The goal is to be a teacher of good, helpful things who passes on all you have learned. When a person continually is learning, and is also continually sharing their knowledge, it completes the circle of intelligent growth. It also keeps you in a positive stance for whatever your career is doing and enhances any job.

About the Author

Erin KennedyErin Kennedy, MCD, CMRW, CERW, CEMC, CPRW is a Certified Master & Executive Resume Writer/Career Consultant, and the President of Professional Resume Services, Inc., home to some of the best resume writers on the planet. She is a nationally published writer and contributor of 14+ best-selling career books and has written hundreds of career-related articles. Erin and her team of executive resume writers have achieved international recognition following nominations and wins of the prestigious T.O.R.I. (Toast of the Resume Industry) Award and advanced certifications. She also is a featured blogger on several popular career sites.

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Ready, Set, Go! ICD-10 Starts Now

Lea Chatham April 22nd, 2015

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Kareo ICD-10 Resource CenterOK, no more excuses. With the passing of the new “doc fix” bill (without a delay to ICD-10 included) we are assured that the October 1, 2015 deadline is “on”.


If you are one of the practices that has waited to see what would happen, it is time to get started. You can’t wait any longer. There are less than six months left and lots to do to be sure that your practice can make the transition effectively and prevent or reduce any loss in productivity or revenue.

This is the first in a series of posts recapping the steps to a successful transition. The upcoming posts will cover:

  1. Code mapping
  2. Documentation review and improvement
  3. Financial planning
  4. Training
  5. Testing

But first, you need to check in on your readiness level. Use this ICD-10 Assessment to determine your level of readiness and get your free ICD-10 Success Plan Checklist. Tweet this Kareo story

Watch for our next post on code mapping coming soon. Or visit the Kareo ICD-10 Resource Center for more tools.

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10 Small Practice Topics in the OIG 2015 Work Plan

Lea Chatham April 21st, 2015

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By Lisa A. Eramo

The annual Office of Inspector General (OIG) Work Plan is a goldmine of information pertaining to provider compliance challenges. Unfortunately, most practices are completely unaware of this document and the valuable information it includes, says Amy Bailey CHC, CPC, COC (CPC-H), CPC-I, CCS-P, principal of HBE Advisors LLC. Bailey, who helps practices maintain compliance through auditing and recommended corrective action plans, says the OIG Work Plan can serve as the basis for a practice’s overall compliance plan.

The OIG 2015 Work Plan was released on October 31, 2014. In it, the OIG raises compliance issues related to chiropractors, radiologists, ophthalmologists, physical therapists, and more. Bailey reviews some of the highlights that pertain to physician practices, including insight into what specific issues the OIG may be targetingTweet this Kareo story

Anesthesia services—payments for personally performed services

  • What the Work Plan says: The OIG will review claims with an AA modifier (used to denote anesthesia services personally performed by an anesthesiologist) to determine whether this modifier is appropriate. Modifier QK, which indicates that an anesthesiologist did not perform these services, limits payment to 50% of the Medicare-allowed amount.
  • How to maintain compliance: Practices need to append each modifier correctly, depending on who administers the anesthesia, says Bailey. This issue mostly pertains to anesthesiologists rendering general anesthesia in a hospital setting. Office-based anesthesia is more likely a sedation type of service that is coded and billed differently, she adds.

Chiropractic services—Part B payments for noncovered services

  • What the Work Plan says: The OIG will take a closer look at unallowable Medicare payments for chiropractic services, including Part B payments for manual manipulation of the spine to correct a subluxation when the patient has a neuro-musculoskeletal condition for which manipulation is appropriate treatment. Maintenance therapy is not medically reasonable or necessary.
  • How to maintain compliance: Some practices simply use a covered diagnosis code that isn’t justified by the documentation. This can definitely raise a red flag to auditors, says Bailey. Medical record documentation—including the ICD-9 diagnosis code used for billing—must accurately reflect the patient’s condition, she adds. If the patient receives treatment for ongoing chronic pain, physicians shouldn’t expect Medicare payment.

Chiropractic services—Questionable billing

  • What the Work Plan says: The OIG will identify inappropriate payments in light of a recent audit that identified a chiropractor with a 93% claim error rate and inappropriate Medicare payments of approximately $700,000.
  • How to maintain compliance: As mentioned previously, documentation must clearly reflect the true reason why the patient receives treatment. If the treatment is performed for a non-covered diagnosis, the chiropractor may be able to bill the patient directly.

Diagnostic radiology—Medical necessity of high-cost tests

  • What the Work Plan says: The OIG will determine whether these tests were medically necessary and whether the use of such tests has increased over time.
  • How to maintain compliance: High-cost radiology tests include advanced imaging services such as CTs and MRIs. The compliance issue is that some referring physicians order these tests without having a medically legitimate reason to do so. Bailey says radiology centers should take the time to verify the diagnosis on the physician order to ensure that it’s correct and as specific as possible. Ideally, the order should reflect a medically necessary diagnosis. If the diagnosis is non-covered, the center may be able to bill the patient directly.

Imaging services—Payments for practice expenses

  • What the Work Plan says: The OIG will review Part B payments to determine whether the practice expense component of these payments is appropriate. These expenses include office rent, wages, and the cost of maintaining and using equipment.
  • How to maintain compliance: The OIG is likely trying to understand whether its payment for the fixed components of the service are accurate, says Bailey. However, this issue may pertain to physicians who inappropriately submit claims for both a professional interpretation as well as the technical component that includes overhead. For example, this could occur when physicians interpret images in the hospital setting. When this is the case, physicians aren’t entitled to payment for the technical component. Instead, physicians should report modifier -26 when performing the professional interpretation only.

Selected independent clinical laboratory billing requirements:

  • What the Work Plan says: The OIG will identify labs that routinely submit improper claims and recommend recovery of overpayments.
  • How to maintain compliance: Bailey says clinical labs should be on the lookout for these compliance traps:
    - Furnishing lab services without a physician order
    - Submitting claims with a payable diagnosis that’s not supported by documentation
    - Billing a code for a comprehensive lab panel when the lab doesn’t perform all of the tests within that panel
    - Billing for analyses of hospital specimens (Note: The hospital should bill for this. Labs receive compensation via a contractual agreement with the facility.)

Ophthalmologists—Inappropriate and questionable billing

  • What the Work Plan says: The OIG will determine the locations and specialties of providers with questionable billing practices.
  • How to maintain compliance: As with many issues in the Work Plan, medical necessity may be a driver, says Bailey. The OIG may look for widespread patterns of non-compliance in certain states or regions. Accurate and thorough documentation is important.

Physicians—Place-of-service coding errors:

  • What the Work Plan says: The OIG will review Part B claims for services performed in ambulatory surgery centers and hospital outpatient departments to determine whether the place-of-service code is correct. Physicians receive higher reimbursement when a service is performed in a non-facility setting, including the practice setting.
  • How to maintain compliance: Place-of-service codes have been a compliance target for many years, says Bailey. Sometimes an office place-of-service is automatically pre-populated into a practice’s billing system. When this is the case, a coder must manually override the information to reflect that a service was performed in a facility setting. Coders must be cognizant of the setting in which a service takes place. This information ultimately affects what physicians are paid, and it can potentially leave them vulnerable to overpayments. It’s important to establish open lines of communication between the practice and facility so coders have the most accurate information possible.

Physical therapists—High use of outpatient physical therapy services

  • What the Work Plan says: The OIG will determine whether therapy services provided by independent physical therapists were medically reasonable and necessary. The OIG will focus on those with a high utilization rate for outpatient physical therapy services.
  • How to maintain compliance: Medical necessity is key, says Bailey. With physical therapy, there is an expectation that patients will improve in a predictable period of time. Medicare also expects a physician to approve a specific plan of care with which therapy will be consistent. Physical therapists must provide as much documentation as possible to capture the patient’s improvement or lack thereof. For example, documentation to support the fact that a patient is progressing at a slower rate than anticipated is critical to help justify why additional therapy visits may be necessary.

Sleep disorder clinics—High use of sleep-testing procedures:

  • What the Work Plan says: The OIG will assess the appropriateness of payments for high-use sleep testing procedures, including codes 95810 and 95811.
  • How to maintain compliance: The OIG is targeting repeated diagnostic testing performed on the same beneficiary when prior test results are still pertinent. Clinics must ensure that any and all tests performed are reasonable and necessary. The physician documentation and order must support this medical validation as well, says Bailey.

Tips for using the Work Plan
Take the following steps when the OIG releases its annual Work Plan:

  1. Review the plan. What topics pertain to your specialty?
  2. What are the new issues? Many of the same issues repeat from year to year. Pay close attention to any new areas on which the OIG is focusing.
  3. Pull a sample of records and review for compliance as it relates to the OIG targets.
  4. Perform education to physicians and coders, if necessary.
  5. Perform a follow-up audit to determine whether the problem has been resolved.

About the Author

LisaEramofreelanceLisa A. Eramo is a freelance writer/editor specializing in health information management, medical coding, and healthcare regulatory topics. She began her healthcare career as a referral specialist for a well-known cancer center. Lisa went on to work for several years at a healthcare publishing company. She regularly contributes to healthcare publications, websites, and blogs, including the AHIMA Journal and AHIMA Advantage. Her focus areas are medical coding, and ICD-10 in particular, clinical documentation improvement, and healthcare quality/efficiency.

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Free Webinar: Launch a Successful Medical Practice

Lea Chatham April 16th, 2015

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Register Now!10 Step Plan to Launch a Successful Medical Practice
Wednesday, April 22, 2015
10:00 AM PT, 1:00 PM ET

Learn everything you need to know to decide if opening an independent medical practice is right for you. Tweet this Kareo story


Are you ready to take the leap and step out on your own? Whether you are a newly minted physician or looking to leave a group practice, how do you know if going out alone is the right choice?

In this webinar, startup practice expert Audrey Christie McLaughlin will walk you through a step-by-step process to help you decide if opening your own practice is the right choice. Audrey will offer practical recommendations on:

  1. How to decide if you should open your practice
  2. The initial steps to take prior to leaving your current position
  3. Business models, budgets, timelines, marketing and staffing considerations

Find out everything you need to know to decide if independence is right for you and how to start a new practice successfully.

Register Now

About the Speaker

Audrey McLaughlinAudrey “Christie” McLaughlin empowers physicians to grow their practices and better the lives of the patients they serve. Audrey is the CEO of McLaughlin Sales Group LLC, creator of the series Customer Service from the HEART, and creator of, a sales and consulting firm that specializes in the business of medicine. Audrey has more than 12 years of experience in helping physicians and hospitals provide the best medical care while growing revenue and keeping costs down. She is an expert, entrepreneur, author, speaker, and is active volunteer in her community. 

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April Getting Paid Newsletter Focuses on New Practice Success

Lea Chatham April 14th, 2015

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The April edition of the Kareo Getting Paid Newsletter has tips for launching a successful new practice along with practice marketing best practices. The newsletter also provides a chance to discover upcoming events, news, and resources from Kareo. Plus, learn about how to register for upcoming free educational webinars. Read all this and more now! Tweet this Kareo story


Read Kareo Getting Paid Newsletter Now




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4 Things to Consider When Staffing a New Medical Practice

Lea Chatham April 13th, 2015

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Register Now for webinar on best practices to start a new medical practiceAudrey Christie McLaughlin, RN

How many people does it take to run a medical practice? Sounds like the beginning of bad joke right? It can be, but in this case it is the beginning of how many new medical practices hemorrhage money. When it comes to a straight forward family practice, a few simple tweaks can really improve overhead.Tweet this Kareo story

So how many people does it take to run an office? Assuming the team is properly trained and motivated and the right systems are in place…surprisingly few. For a single physician clinic seeing an average of 30 patients per day (without any ancillary services), you should have three to four team members other than the physician in the entire clinic. Often, I see family practice clinics of this size trying to start with upwards of seven staff members (check in receptionist, check out receptionist, billing specialist, lab tech, two medical assistants and an office manager).

Here is what you need:

  1. Office Manager: In a practice that sees 30 patients per day or less, your office manager should be spending the majority of his or her time assisting with the billing. Your office manager should also back up the receptionist on the phones and check in/checkout. She/he should also be competent enough to fill in for the medical assistant when help is needed on the clinical side. The office manager should be the liaison between the physician and the staff for routine issues (i.e. vacation/sick days, tardiness, payroll, accounting, posting payments, etc.). Remember if you give your office manager the responsibilities, you must also give her the authority to handle issues when they arise without interrupting you several times per day. One great hire for an Office Manager position is an RN with a clinic background, often times they are well versed in the clinical side as well as the billing side of practices.
  2. Receptionist: Your receptionist should be responsible for answering the phone by the second ring (you may elect to have an automated system to answer your phones. I believe a live person is best, but automated will work in a pinch), transferring those phone calls, checking patients in and out, and initiating the billing process at the end of the day. The receptionist, believe it or not, should at a minimum be able to help room patients and understand the flow of the clinical side as well.
  3. Medical Assistant: Your medical assistant (MA) should be able to do his primary jobs quickly and accurately and utilize communication to move the patients through the clinic quickly while anticipating the needs of the patient and physician. MAs should take vitals, height and weight, get a brief description of the reason for the visit, and walk the patients to and from the front desk/waiting room. The physician should never be standing around waiting on the next patient. In addition, your MA should be the backup for the receptionist and have an understanding of the billing side so they can fill in there as well. (Those types of fill-ins may be necessary when the physician is out of town or in the case of one and a half MA’s on staff.)
  4. Billing Specialist OR Outsourced Billing: Depending on the rates and benefits you can negotiate from billing companies, it may be in your best interest to utilize a billing company rather than a live body in your office. The billing position is one of the few positions that I don’t believe should habitually dual-role. You want your biller focused on your billing and revenue. Consider outsourcing your billing and hiring an additional part-time Medical Assistant if you feel the drag with less than four staff members.

If you haven’t noticed the pattern already, I am going to spill the beans: Everyone in your clinic should be cross-trained and eager to jump in wherever and whenever it is needed. Tweet this Kareo story
This is critical to the success of a practice of any size, but especially important when you are conserving overhead and launching a new medical practice.

As you grow in patient volume or practitioners, it will become necessary to add additional staff members. Typically, that begins with an additional MA to help first, then additional reception help and finally (if you aren’t using a service) additional billing help.

To find out more about best practices to start a new medical practice, join me for my upcoming free webinar, 10 Step Plan to Launch a Successful Medical Practice, on April 22. Register Now!

About the Author

Audrey MAudrey “Christie” McLaughlin empowers physicians to grow their practices and better the lives of the patients they serve. Audrey is the CEO of McLaughlin Sales Group LLC, creator of the series Customer Service from the HEART, and creator of, a sales and consulting firm that specializes in the business of medicine. Audrey has more than 12 years of experience in helping physicians and hospitals provide the best medical care while growing revenue and keeping costs down. She is an expert, entrepreneur, author, speaker, and is active volunteer in her community.

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3 Tips to Get Your Practice Website Right

Lea Chatham April 13th, 2015

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Tweet this Kareo StoryBy John Lynn

One of the biggest challenges a practice faces is finding new patients. In most areas, competition for patients is fierce and the methods that patients are using to find a doctor are changing rapidly. Tweet this Kareo story
While many consider these changes a problem, they can also be seen as a great opportunity for your practice. Let’s take a look at one of  the many ways you can make sure you’re marketing your practice in the most effective way possible–your website.

Your organization’s website is patients’ first impression of your practice. What impression does your website make? Does it say that I’ve been practicing medicine since the 80’s and haven’t updated my website since then? Does it make it easy for patients to quickly connect and communicate with you to get their questions answered and their appointments scheduled?

Right or wrong, many patients judge a doctor’s medical proficiency based on the quality of their website. Many patients reason that if the doctor isn’t keeping their website up to date, then what else in their practice aren’t they keeping up to date? This is why it’s extremely important that a practice make sure that their website provides a high quality first impression.

Here’s a look at some features of a modern practice website:

  • Clean, Professional Design: We all know a well designed website when we see it. Without going into all the latest design trends, I’ve found the key to a clean, professional website design is to actually employ a designer in the process. While any programmer can build a website, the results are dramatically better looking when a designer designs the website and a programmer implements that design. One is focused on function and the other is focused on appearance. Marry the two and you’ll have a professionally designed website that matches the way you practice medicine.
  • Mobile Friendly: If your website is not mobile friendly, you’re likely missing out on patients. More and more web browsing is being done on our mobile phones. This is especially true for the younger generation, but is true for the older generation as well. Many in the older generation don’t use a computer at all, but now use their iPad or other tablet device for all their web browsing needs. So, your website needs to look great on mobile devices. When making your website mobile friendly, ask your web development team to make sure they provide you a responsive design. They’ll know what I’m talking about. If they don’t, find a new development team.
  • Secure Contact Options: One of the biggest missed opportunities for practices is when a patient visits a practice website and their only option to get questions answered (i.e., Do you take my insurance?) and schedule an appointment is to call. Many patients are at work or unable to call. Plus, patients dread the idea of getting stuck in some awful phone tree. Make it easy for patients to become a new patient by offering a secure online contact option. Plus, this saves you having to play phone tag with them when you miss their call.

Whether a new patient discovers you on their insurance list, a referral from a friend, or a Google Search, their next step is often a visit to the doctor’s website. Make sure your website gives off the right first impression and converts those website visitors into new patients.

Your practice website is just one place to start with your practice marketing efforts. There are many more options including review sites and social media to name a few. We’ll be diving deeper into these and many other practice marketing tips in my free webinar,  5 Marketing Tips to Get New Patients Now on May 6. Register Now!

About the Author

John Lynn is the Editor and Founder of the nationally renowned blog network John also co-founded two companies: and Plus, John is the Founder of 10 other blogs including the Pure TV Network and Vegas Startups. John’s 25+ blogs have published over 15,000 blog posts, garnered over 30 million views and had over 122,000 comments. John is highly involved in social media, and in addition to his blogs can be found on Twitter: @techguy and @ehrandhit and LinkedIn.

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Worries and Warnings: What Really Triggers a Payer Audit?

Lea Chatham April 8th, 2015

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Tweet this Kareo storyBetsy Nicoletti

“I’ve heard that I might get audited if I bill too many level 4 visits.”  “I told her that if she kept using that modifier so much she’d get audited!” How many times have you heard a statement like this? Either a clinician is worried about a payer audit, or a coder or consultant is warning about an audit. Both worries and warnings can cause clinicians to under code, hoping to “fly under the radar.”

What really increases the risk of an audit from Medicare or government payer? Tweet this Kareo story

Every coder and clinician can cite some obvious risks. Using high level codes at a higher frequency than the norm for the specialty or using modifiers 25 or 59—one of the modifiers that bypasses the claims editing system—at a particularly high rate. These are the most obvious topics for worries and warnings. The problem, however, is that the government and private payers have claims data for all physicians who participate with them and can sort it by specialty. That is, third parties know how frequently an orthopedist uses modifier 25, but how does an orthopedic practice know this? What is the frequency of high level visits reported by cardiology? The payers have a full deck of cards and we have only the ace of spades and the two of clubs. Some data is available for purchase by commercial vendors, but not all practices have access to it. In the absence of that data, here are some things that you can do:

  • In a large group practice, compare physicians of the same specialty for frequency of high-level visits and use of modifiers. Check with your specialty society for any normative data that they have available for members on E/M frequency or the use of modifiers.
  • The OIG identified clinicians who were reporting the two highest levels of service in every category more than 95% of the time. Look at your clinicians and compare the percentage that each reports of the two highest levels codes in each category.
  • Many groups have access to MGMA work relative value unit (RVU) data. A clinician with very high volume compared to the MGMA median may be the target of an audit.
  • Pay attention if you receive a letter from a third party payer that a clinician uses a high level code or a modifier more frequently than the norm. This is an indication for an internal audit.

Some types of service are also higher risk than others. How do you find out what those services are? There are three sources of publicly available information. Review the annual OIG Work Plan. It lists areas that the government considers to be areas of interest. Look at the RAC list of issues for your region. These can be sorted by type of provider, making it easy to see what physician services are RAC targets. Review the Medicare CERT reports which identify types of service and, sometimes, specific CPT codes that have a high error rate. Providing services that are on one of these lists, especially at a high volume, does increase your risk of audit. Decrease worries by identifying these services, reviewing the coding rules related to each one and doing an internal audit. Consider these three sources—the OIG Work Plan, RAC issues and CERT reports—as warnings that will allow you to decrease your worries.

Want to learn more? Check out Betsy’s recorded webinar, Coding Pitfalls & Promises.

About the Author

Expert Betsy_Nicoletti_advises how to improve your patient collectionsBetsy Nicoletti is the author of The Field Guide to Physician Coding and the 2007 Physician Auditing Workbook, as well as founder of She developed The Accurate Coding System to help doctors get paid for the work they do. She simplifies complex coding rules for practitioners and engages physicians in a positive and respectful way, which encourages attention and accuracy in their coding. Besides doing auditing and compliance work, she is a speaker, writer and consultant in coding education, billing and accounts receivable. 

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Welcome to Getting Paid, a weblog by Kareo offering ideas, news and opinions about medical billing and practice management with the goal of making medical billing easier and yes, getting you paid. Visit the Product Blog for more information on our products.

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Improve patient care with electronic charting, electronic prescribing and medical labs interfaces.

Medical Billing & Collections

Streamline your entire medical billing and collections process from charge entry to reporting.

Clearinghouse Services

Integrated electronic claims, electronic remittance advice and insurance eligibility services.

Analytics & Data

Store and access data with insightful reports, document management and faxing, and an integration