Should There be a National Standard for Certification of Auditors?

Certify the certifiers.

Have you ever been in a Medicare hearing and realized the person testifying for the auditor does not understand what they are talking about?

Recently, I was in such a hearing. A number of claims filed by my client had been rejected because of poor documentation. Now, why was that? The auditor testified that the physician had failed to document the parts of the body involved.

But this was not true. Each of the patient notes had detailed each muscle group involved.

What was the problem? It soon became clear that the auditor did not know how to read the abbreviations in the notes.

Now, of course, one could argue that if a physician were using some special code in their documentation, this might raise eyebrows. But that wasn’t the case here.

In fact, each of the abbreviations used was a standard, accepted in this particular area of practice. Any person even remotely familiar with the specialty knows these abbreviations. And all physicians in this area of practice use them.

So, what was the problem? What was going on?

Why was the auditor unable to read and understand the medical documentation they were rejecting?

In my view, it is a matter of certification. The auditor was not adequately trained to read the documentation. As a consequence, they were not qualified to perform the audit, and they certainly were not qualified to testify against this provider in a Medicare hearing, when the issue on the table was poor documentation.

In the medical world, certification is the universal currency of credibility. Before they are allowed to treat patients, doctors go through years of training.

But supporting the doctor is an ocean of persons with certifications. In one list from the Centers for Medicare & Medicaid Services (CMS), I counted 116 certifications.

In diagnostics, we find separate certifications in audiology, X-ray technicians, sonograms, vascular, electroneurodiagnostic technology, radiation health technology, and radiation safety.

In the treatment area, we find certifications in massage, anesthesia, basic life support, cardiovascular, paramedics, cytogenics, dental assistants, dental radiation, dialysis, EMT, exercise kinesiology, CPR, phlebotomy, geriatric management, histologist, herbology, oral surgery, speech therapy, and naturopathy.

In health administration, there are even more. Health services management, coding, health informatics, billing, insurance coding, hospital case management, medical administration, safety certification, clinical data management, and more.

There is even a certification in pet CPR.

But what about the auditors?

To obtain a certification in physician practice management, one needs to take a 200-question exam for $399. The book to prepare is 118 pages long, and costs $169.

Certification in medical documentation is 150 questions, with another short paperback to study.

An undergraduate degree in Texas requires 120 credits; auditors require 60.

A medical necessity course is 60 minutes long and costs $49.

In the United States, we may have a horrible mismatch between the auditors and the providers being audited.

It begs the question about whether there should be a national standard for certification of auditors.

We can think about certifying the certifiers.


Edward M. Roche, PhD, JD

Edward Roche is the director of scientific intelligence for Barraclough NY, LLC. Mr. Roche is also a member of the California Bar. Prior to his career in health law, he served as the chief research officer of the Gartner Group, a leading ICT advisory firm. He was chief scientist of the Concours Group, both leading IT consulting and research organizations. Mr. Roche is a member of the RACmonitor editorial board as an investigative reporter and is a popular panelist on Monitor Mondays.

Related Stories

New Workflow Manages DRG Mismatches

Workflow increases productivity, while proving itself to be successful in reconciling DRG mismatches. When asking many clinical documentation improvement specialists (CDISs) what they dislike most

Read More

Leave a Reply

Your Name(Required)
Your Email(Required)

Featured Webcasts

Implantable Medical Device Credit Reporting for 2023 – What You Need to Know

Learn how to save your facility hundreds of thousands of dollars in repayments and fines by correctly following CMS requirements for implantable medical device credit reporting. We provide you with all the need-to-know protocols, along with the steps for correct compliance while offering best practices to implement a viable strategy in your facility.

January 25, 2023

Trending News