Has your practice ever gotten notified that you’re an outlier? If so, you may realize the fear this can create, and the possibility that you may end up getting audited or seeing your claims downcoded. Not every outlier letter means you’ll face lost revenue, but it can still be upsetting.

Check out a few steps to take if your payer tells you that your practice is an outlier.

Know What an Outlier Is

Your first step is to understand exactly what it may mean if you’re branded an “outlier” by your payer. In most cases, this means that your codes are outside of the norm for your specialty, region, patient population, or some combination of these.

For example, perhaps you’re an internal medicine provider who bills most of your visits using place of service (POS) code 12 (Home), whereas most internal medicine physicians in your area use POS code 11 (Office). The payer may wonder why you’re billing so many visits in the patients’ homes.

Or maybe your dermatology practice reports mostly 99215s for established patients, whereas the majority of dermatologists near you bill mainly 99213s. The insurer is likely to ask for your records to demonstrate why most of your patients required the highest level of outpatient care.

Check Your Records

If you’re considered an outlier, you should evaluate your documentation to make sure you were justified in reporting codes that were outside of the norm. For instance, in the example above, the dermatology practice that reported mostly 99215s may specialize in treating metastatic melanoma, which require significant time with the patient and conferring with other providers. As long as the time or medical decision-making supporting 99215 is reflected in the documentation, the payer should be able to see the legitimate reasons why you’re an outlier.

Once you have a handle on why your practice is billing codes outside of the averages, you can move on to the next step.

Share Findings With Providers

If you find that some of your codes were reported incorrectly, educate the providers, coders and billing staff about the issues you discovered. Advise them about how to select the right codes so you aren’t miscoding your services and putting your practice at risk of overpayments and compliance violations. If you identify any overpayments, send them back to the payer with an explanation of what you found.

Talk to Your Practice’s Attorney

If you’re nervous about the fact that your practice is considered an outlier, it may be a good idea to discuss it with your practice’s healthcare attorney. They can advise you on next steps, and may refer you to a consultant that can accurately determine whether your coding processes are working the right way or if they need to be adjusted.