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Question: A colleague of mine who works as a coder at another location of the same medical practice recently underwent an audit for practitioners billing for 鈥渋mprobable time.鈥� This has raised my concerns about the possibility of our location being audited next. What is improbable time, and how can we prevent being audited for it in the future?

Ohio Subscriber

Answer: Improbable time is when auditors, billers, or payers notice that the amount of time practitioners report having spent with patients is improbable 鈥� or even impossible 鈥� based on a normal workday or workload.

Keep in mind that although insurance companies typically don鈥檛 have insight into the exact number of patients a healthcare provider sees in a day due to the diversity of insurance carriers among patients, they are still able to assess the appropriateness of the time a provider spends with a patient by comparing that provider's reports to others offering the same service, a method known as outlier detection.

The Healthcare Fraud Prevention Partnership (HFPP), a voluntary, public-private partnership between 284 entities, shares information and data concerning healthcare fraud. As part of the HFPP, the Centers for Medicare & Medicaid Services (CMS) and other federal agencies, as well as commercial carriers, have zeroed in on improbable time in their evaluations of coding and billing waste, fraud, and abuse.

The U.S. Department of Health and Human Services (HHS) and Office for Inspector General (OIG) have brought enforcement actions against individual physicians for Medicaid and Medicare fraud, respectively. Commercial payers also investigate, audit, and even hit organizations with sanctions or penalties.

Going forward, avoiding an audit for improbable time is simple: Make sure all time is supported and accurate with proper documentation from the practitioner. Don鈥檛 fudge the numbers.

Lindsey Bush, BA, MA, CPC, Production Editor, AAPC