Mental Health Compliance Auditor Needed- Payer Chart Audit, DEA Audit, and RCM Forensic Audit

Independent Psychiatry Practice Compliance and Revenue-Cycle Review ABOUT THE PROJECT I own a growing multi-state outpatient psychiatric practice and am looking for an experienced, independent healthcare compliance professional or firm to conduct a comprehensive audit of three critical areas of the practice: Payer-style clinical documentation and coding audit DEA and controlled-substance documentation/compliance audit Revenue-cycle management and billing audit I do not want a superficial review. I want someone to examine the practice from the perspective of: A commercial insurance auditor reviewing my charts A Medicare or government payer reviewer examining documentation and coding A DEA or controlled-substance compliance reviewer examining prescribing practices, records, workflows, and documentation An experienced RCM auditor attempting to determine exactly where revenue is being lost The objective is to identify vulnerabilities now, correct them, establish better systems, and reduce the risk of denials, recoupments, repayment demands, compliance problems, and lost revenue as the practice grows. This is a behavioral-health and psychiatry practice. Experience auditing psychiatry, behavioral health, psychiatric medication management, psychotherapy add-on coding, controlled-substance prescribing, and PMHNP documentation is strongly preferred. WORKSTREAM 1 — PAYER-STYLE CLINICAL DOCUMENTATION AND CODING AUDIT I want a sample of my clinical records reviewed as though an insurance company had requested the charts for a prepayment or post-payment audit. Do not simply tell me whether the notes look clinically appropriate. Determine whether the documentation actually supports what was billed. CMS states that medical-record documentation must support the CPT, HCPCS, and ICD-10-CM codes reported and that medical necessity is a central criterion for payment. Review areas including: Medical necessity CPT selection ICD-10 diagnosis support Evaluation and management coding Medical decision-making Time-based coding where applicable New versus established patient coding Psychiatry documentation Medication-management documentation Psychotherapy add-on documentation Separation of psychotherapy from E/M work Psychotherapy time documentation Treatment-plan documentation Assessment and plan Risk assessment Medication changes Prescription-management documentation Follow-up rationale Telehealth documentation where applicable Authentication/signature requirements Documentation consistency Cloned or repetitive documentation Internal contradictions Documentation that appears templated without sufficient patient-specific information Documentation that does not support the level of service billed Documentation that may create unnecessary audit risk Common codes used in the practice may include: 99204 99205 99213 99214 99215 90833 90836 and other appropriate outpatient psychiatric codes. OIG specifically emphasizes accurate coding, medical necessity and documentation, and notes that provider documentation forms the basis for claims submitted to payers. I WANT YOU TO AUDIT ME LIKE A PAYER WOULD For each sampled chart, provide a clear determination such as: PASS LOW RISK MODERATE RISK HIGH RISK DOES NOT SUPPORT CODE BILLED Then tell me exactly why. For example: Billed: 99214 plus 90833 E/M supported: Yes or No 90833 supported: Yes or No Medical necessity supported: Yes or No Diagnosis supported: Yes or No Time requirements supported: Yes or No Major vulnerabilities: ______ Potential payer concern: ______ Recommended correction for future documentation: ______ I want actionable feedback, not simply a compliance score. PSYCHOTHERAPY ADD-ON AUDIT This deserves specific attention. Review my use of psychotherapy add-on codes and determine whether documentation appropriately supports them. Evaluate: Psychotherapy time Psychotherapy intervention Therapeutic focus Patient response Progress Separation from E/M activities Medical necessity Consistency between documented time and billed services I specifically want to know whether my current documentation would withstand an aggressive commercial-payer review. PAYER-SPECIFIC RISK Where reasonably possible, identify differences or vulnerabilities involving major payers with which the practice works. This may include commercial insurers and federal programs as applicable. I am particularly interested in knowing whether documentation practices create risk for: Denials Downcoding Prepayment review Post-payment review Recoupment Medical-necessity challenges Psychotherapy add-on challenges Coding-pattern scrutiny CMS describes its own medical reviews as clinical reviews of records to determine whether services meet coverage, coding, billing and medical-necessity requirements. WORKSTREAM 2 — DEA AND CONTROLLED-SUBSTANCE COMPLIANCE AUDIT This is separate from the payer audit. I want someone genuinely qualified in controlled-substance compliance to review the practice's prescribing documentation and workflows. The practice provides psychiatric care and may prescribe controlled medications when clinically appropriate. I want the practice reviewed proactively for vulnerabilities involving controlled-substance prescribing. Areas for review should include, as applicable: Controlled-substance documentation Prescribing workflows DEA registration considerations Multi-state practice considerations Telemedicine prescribing workflows Patient identity and required information Controlled-substance treatment rationale Documentation of indication Risk-benefit documentation Monitoring Follow-up frequency PDMP/PMP review documentation Urine or other drug-screening practices when clinically indicated Controlled-substance agreements when applicable Early refill requests Lost medication requests Multiple prescribers Multiple pharmacies Aberrant medication behavior Diversion concerns Substance-use history Concurrent controlled substances Benzodiazepine risk Stimulant prescribing Opioid-related considerations when applicable Documentation of patient education Informed-consent/risk discussions Medication quantities Refill practices Staff handling of controlled-substance requests Delegation and escalation Record retention E-prescribing processes State-specific considerations I want the auditor to distinguish clearly between: Federal DEA requirements State requirements Payer requirements Clinical best practices Risk-management recommendations These are not always the same thing, and I do not want them presented as though they are. MULTI-STATE CONTROLLED-SUBSTANCE REVIEW The practice operates across multiple states. The auditor should be able to identify when state-specific legal or regulatory review is needed and should not assume that one state's requirements apply everywhere. If you are not qualified to provide legal interpretation, that is fine. I expect you to clearly identify: What is a compliance requirement What is a recommended practice What requires healthcare attorney review What requires state-specific regulatory verification CONTROLLED-SUBSTANCE CHART AUDIT Review a sample of controlled-substance charts and tell me: Would this record concern you if you were reviewing the prescribing? Is the clinical indication apparent? Is ongoing prescribing justified? Is monitoring apparent? Are risk factors appropriately addressed? Is PDMP review documented appropriately? Are concerning refill patterns visible? Are there documentation gaps? Does the record demonstrate longitudinal monitoring? Would an outside reviewer understand why the medication was initiated and why it is being continued? What should be documented differently going forward? I want specific examples and corrective recommendations. STAFF WORKFLOW REVIEW I also want the controlled-substance audit to examine what happens when administrative or clinical support staff receive messages involving: Stimulant refills Benzodiazepine refills Early refill requests Lost medication Pharmacy changes Dose-change requests Side effects Requests involving controlled substances Concerning patient communications I want clear recommendations for: What staff may handle administratively What must be escalated to the prescriber What belongs in the medical record What should not be handled solely through administrative communication What documentation should exist WORKSTREAM 3 — FORENSIC RCM AND BILLING AUDIT I am concerned that I currently do not have adequate visibility into my billing and revenue cycle. I need an independent auditor to determine exactly what is happening with the money. This is not simply: Review my aging report. I want reconciliation. RECONCILE SERVICES RENDERED TO MONEY COLLECTED Where data permits, trace encounters through the revenue cycle: Date of service to Service documented to CPT billed to Charge entered to Claim created to Claim submitted to Payer response to Allowed amount to Payment to Patient responsibility to Patient payment to Final balance I want to identify where that chain breaks. AUDIT FOR MISSING REVENUE Specifically identify: Encounters never billed Claims never submitted Claims submitted late Rejected claims Denied claims Claims requiring correction Claims never followed up Underpayments Contractual adjustment problems Payment-posting errors Unapplied payments Credit balances Patient balances Incorrect write-offs Missing copays Missing deductibles Claims affected by credentialing Claims affected by enrollment Claims affected by authorization Claims sitting without action Revenue that may still be recoverable OIG's guidance for third-party billing companies specifically discusses pre- and post-submission review, documentation supporting claims, coding practices and credit balances as compliance areas. ACCOUNTS RECEIVABLE AUDIT Break AR into: 0 to 30 days 31 to 60 days 61 to 90 days 91 to 120 days Over 120 days Then tell me: How much is outstanding? Who owes it? Why is it outstanding? What has been worked? What has not been worked? What is collectible? What is at risk of timely-filing expiration? What may need appeal? What may need corrected claims? What should have been collected from patients? What appears unrecoverable? What should happen next? DENIAL AUDIT Categorize denials. Examples: Eligibility Credentialing Authorization Coding Medical necessity Timely filing Duplicate Coordination of benefits Demographic error Documentation Provider enrollment Payer processing error Other Then calculate where possible: Denial rate Denial dollars Recovered denial dollars Unworked denial dollars Average denial age Top denial reasons Most problematic payer Most problematic workflow CURRENT BILLER PERFORMANCE AUDIT I currently use an outside billing resource and want an independent assessment. I want to know: Are claims being submitted promptly? Are payments being posted correctly? Are denials actually being worked? Is AR being followed? Are patient balances being managed appropriately? Are claims falling through the cracks? Are adjustments appropriate? Are reports accurate? Are follow-ups documented? Are outstanding balances aging unnecessarily? Are credentialing issues affecting reimbursement? Is the billing operation performing at a level appropriate for a growing psychiatric practice? I want objective findings supported by data. CREDENTIALING AND ENROLLMENT INTERSECTION Where relevant, identify revenue problems related to: Provider enrollment Credentialing Effective dates Network status Group versus individual enrollment Incorrect payer setup Revalidation Missing applications Closed applications Credentialing delays Claims submitted before effective dates Claims submitted incorrectly as out-of-network I do not necessarily expect this project to complete all credentialing. I do expect the auditor to identify where credentialing is causing financial leakage. FINAL DELIVERABLE 1 — EXECUTIVE RISK REPORT I want a concise owner-level report showing: CRITICAL — FIX IMMEDIATELY HIGH RISK MODERATE RISK LOW RISK WORKING WELL I should be able to understand the major risks without reading 100 pages. FINAL DELIVERABLE 2 — PAYER AUDIT SCORECARD Provide findings for sampled charts including: Code billed Code supported Medical necessity Documentation sufficiency Psychotherapy support where applicable Risk level Problem identified Recommended correction FINAL DELIVERABLE 3 — DEA AND CONTROLLED-SUBSTANCE SCORECARD Provide findings regarding: Documentation Prescribing rationale Monitoring PDMP workflow Refill workflow Staff escalation Controlled-substance risk management State-specific issues requiring further review Recommended corrective actions FINAL DELIVERABLE 4 — RCM FINANCIAL AUDIT Show me: Total AR AR aging Unbilled encounters Denials Unworked denials Underpayments identified Patient balances Unapplied payments Potential recoverable revenue Revenue at risk Credentialing-related revenue problems Top financial leakage points FINAL DELIVERABLE 5 — CORRECTIVE ACTION PLAN Do not just tell me what is wrong. Tell me exactly how to fix it. For every significant finding provide: Problem Risk Priority Recommended correction Who should own the correction Recommended deadline How we prevent recurrence FINAL DELIVERABLE 6 — DOCUMENTATION IMPROVEMENT GUIDE I want practical recommendations that I can incorporate into my psychiatric documentation. This may include recommendations for: New-patient evaluations Follow-up medication-management notes 99214 documentation 99215 documentation 90833 documentation 90836 documentation Controlled-substance visits ADHD/stimulant follow-ups Telehealth visits Safety documentation Medical necessity Treatment-plan documentation I do not want bloated notes created merely for defensive documentation. I want efficient documentation that accurately supports the care delivered and the services billed. FINAL DELIVERABLE 7 — STAFF TRAINING After the audit, provide a live session with the owner and relevant staff. Explain: What you found What creates the greatest risk What needs to change immediately What staff should document What staff should escalate What billing staff should monitor What the provider should change How we should conduct internal audits going forward QUALIFICATIONS Strong candidates may have credentials or backgrounds such as: Certified Professional Coder Certified Professional Medical Auditor Certified Coding Specialist Certified in Healthcare Compliance Certified Professional Compliance Officer Healthcare attorney with relevant experience Experienced behavioral-health compliance consultant Experienced psychiatry coding auditor Experienced RCM auditor Controlled-substance compliance professional Former payer auditor Former healthcare fraud, waste and abuse investigator Other comparable healthcare compliance credentials and experience I care about demonstrated expertise more than collecting acronyms. REQUIRED EXPERIENCE Applicants should demonstrate meaningful experience in at least two of these three areas: Payer documentation and coding audits Controlled-substance or DEA compliance RCM and billing audits If you are highly qualified in only one or two areas, please apply and clearly state your limitations. I would rather hire two excellent specialists than one person pretending to be an expert in everything. STRONGLY PREFERRED EXPERIENCE Psychiatry Behavioral health PMHNP practices Outpatient mental health E/M coding Psychotherapy add-on coding 90833 90836 Controlled-substance prescribing Stimulant prescribing Telepsychiatry Commercial payer audits Medicare/CMS compliance Multi-state practices Tebra or Kareo Behavioral-health revenue cycle WHEN APPLYING Please begin your proposal with: PSYCHIATRY AUDIT Then answer the following: Which of the three workstreams are you personally qualified to perform? Payer documentation and coding DEA and controlled-substance compliance RCM and billing What relevant certifications or credentials do you hold? Have you personally audited psychiatry or behavioral-health records? Have you audited E/M plus psychotherapy add-on coding, particularly 99214 plus 90833? Describe your experience with controlled-substance or DEA compliance audits. Describe a revenue-cycle audit where you identified significant lost or recoverable revenue. Have you worked as or with a commercial payer, Medicare contractor, RAC, SIU, compliance department, or other audit organization? How many charts would you recommend sampling initially and why? What financial reports and data would you need to conduct the RCM audit? What would your final deliverables look like? What would you charge for the initial audit? How long would you expect the project to take? Are you available for ongoing quarterly audits after the initial engagement? IMPORTANT I am not looking for someone to simply validate what we are already doing. I want an independent auditor willing to tell me: This is good. This needs improvement. This would probably be denied. This code is not adequately supported. This documentation creates unnecessary risk. This controlled-substance workflow needs to change. This claim should have been paid. This money may be recoverable. This billing process is failing. This needs immediate attention. The purpose of this project is not to create fear. The purpose is to know exactly where we stand before the practice becomes significantly larger. I would rather discover vulnerabilities ourselves and correct them now than have a payer, regulator, or auditor discover them later.