What should be reviewed when auditing a provider who performs consultations?

When auditing a provider who performs consultations, it is essential to review the payer policies. Payer policies give insight into the specific criteria and guidelines that govern how consultations should be billed and documented. Each insurance provider or payer may have different rules about what qualifies as a consultation, including documentation requirements, necessary codes to use, and the circumstances under which consultations can be conducted.

Understanding these policies ensures compliance with billing standards and helps to confirm that the consultations are being adequately supported by documentation. This is particularly important, as improper billing of consultations can lead to denials or audits, which can have financial repercussions for the provider.

While reviewing the provider's credentials and the patient's history can provide context and support practice quality, they do not directly inform the auditing process in the same way that understanding payer policies does. Similarly, office protocols relate more to internal processes rather than compliance with external payer rules. Thus, the focus on payer policies is crucial for an accurate audit of consultation services.