What is an Audit?
An audit is an independent review of an early intervention therapist's documentation, billing, and operational processes. The purpose of the audit is to ensure the therapist follows federal, state, and local regulations and to identify any areas for improvement.
In general, an audit for early intervention therapiss is designed to ensure that children with developmental delays or disabilities receive high-quality and appropriate services, and that public funds are used effectively and efficiently. It can also provide therapists with valuable feedback and recommendations for improving their documentation and processes.
Who Does the Audit?
For Louisiana Early Steps providers, audits are initiated by either Gainwell Technologies (Louisiana Medicaid) or directly from the Early Steps regional offices (your Regional Coordinator). Audits may be triggered randomly, or an audit may be initiated based on an identified need to verify compliance. In most cases, audits are random: providers are selected randomly, and the client charts are selected randomly.
The Audit Process
The audit process for Louisiana Early Steps providers may vary depending on the specific type of audit being conducted. However, the following is a general overview of the audit process for Louisiana Early Steps providers:
Initial Notification: The provider will receive an email notification from either Gainwell Technologies or an Early Steps Regional Coordinator indicating that they have been selected for an audit. The email will include the scope and timeframe of the audit.
Entrance Conference: The provider may also receive a phone call from the auditor to explain the audit process, review the scope and objectives of the audit, and discuss any questions or concerns. TIP: Write down the auditor’s email address/contact information in case you have questions later.
Audit Record Requests: Following the initial notification, the provider will receive a detailed list of records requested for the audit. TIP: Pay attention to the deadline. The provider is typically given only 2 weeks to submit the requested records.
Preparation: The provider will need to gather all requested documentation related to the audit. This information typically includes daily contact notes, monthly notes, IFSP documents, and meeting information.
Auditor’s Review: Once you submit all the requested materials, the auditor will review the submitted client records and billing records.
Audit Report: The auditor will prepare a report summarizing their findings and recommendations. The report will be provided to the Louisiana Department of Health. Gainwell Technologies is not required to notify the provider of the audit results unless there is a problem, or at the discretion of the auditor.
Response: The provider will have an opportunity to respond to the audit findings and recommendations and may be required to develop a corrective action plan to address any issues identified during the audit.
Audit Mistakes to Avoid
The most common mistakes that auditors find are missing or incomplete client records, such as missing goals, lack of progress notes, or missing signatures. Another common mistake is filing claims that are inconsistent with the documentation (i.e., the time on the note does not add up to the number of units on the claim, or the location on the daily note does not match the location of service on the claim).
EasySteps is designed with evidence-based practice in mind to help early intervention therapists avoid these common mistakes! In a peer-reviewed article in the Open Journal of Occupational Therapy (Raymond et al., 2020), an early intervention therapist using the EasySteps app wrote more accurate and comprehensive documentation with improved clinical reasoning and rationale for therapy services.
How EasySteps Helps:
Proper Billing: EasySteps One-Click Billing uses a unique automatic claim generation. Claims are automatically created using information directly from the corresponding daily note. This ensures that key elements of your claims such as length of service and location of service match your documentation exactly, eliminating the risk of inaccurate claims! EasySteps automatically uses the correct billing codes consistent with the documentation. Plus, EasySteps features built-in claim scrubbing to ensure that claims are submitted correctly the first time!
Checkboxes for Goals and Skilled Interventions: Another common mistake therapists make is omitting required information simply because of lack of time. EasySteps makes it easy to add goals and interventions! Once a goal is typed, EasySteps remembers the information, so you don’t have to type it again. Just check your goal and interventions from your customized picklist to autofill on the note.
Auto-Population: When using EasySteps, client data, such as the client’s name, gender, date of birth, outcomes, and goals are documented into the EHR system. The client data automatically populates into all documents created for that client, saving the user more time by eliminating redundancy.
Signatures: Both Medicaid and Early Steps require the caregiver signature to be on every daily contact note. With EasySteps, signatures are easy! The caregiver can sign their name to the note directly on the iPhone/iPad with their finger!
The Magic Wand: Once you ae done writing a daily note, click the magic wand. The magic wand checks the note for errors and missing information.
Document Saver Boxes: EarlySteps requires the therapist to maintain records of all IFSPs. Although the IFSPs are stored on the EarlySteps Online website, the therapist should store the IFSP separately in the event of an audit. If the therapist does not have an active authorization for the charts being audited, the therapist will not have access to those documents on EarlySteps Online. EasySteps has container boxes located inside every client chart that allows you to store IFSPs and keep all your client records in one easily accessible place!