Spice Up Documentation: Bring on the PEPPER

Frank Cohen joins us now to wrap up part three in his three-part series, AI Encoding.

And good morning, Frank.

Good morning, Chuck.

So over the last two weeks, what I've talked about is this chess match analogy and how practicing doing everything right at the chart level can still result in an extrapolated overpayment demand.

This week asked the question, so what do you actually do when the demand letter shows up? Now, traditionally, defending an audit has meant defending charts, right? The defense team pulls the records.

They walk through the documentation.

They argue the coding one claim at a time.

And that work still matters, especially at the ALJ level.

But if the audit was triggered by a statistical model that's looking at your data in that aggregate, winning on individual charts does not necessarily get you out from under the extrapolation.

Now, the sampling, the stratification, the extrapolation math, that machinery is doing most of the work.

I've served as a statistical expert in hundreds of these extrapolation matters over my career.

And the cases where providers prevail at scale are almost always those in which the methodology was challenged.

And that's really where the leverage is.

So what does the defense look like now? I have put together three pillars.

So pillar one is challenging the methodology, not just the chart.

So the contractor's statistical methodology is almost always the softest target in the room.

Sampling frames get built sloppily, strata get defined in ways that violate the contractor's own protocols, and extrapolation math gets applied to populations that look nothing like the sampled claims.

And if your defense team is only arguing clinical merits, they're leaving the strongest ground untouched.

Pillar two, demand to see the model.

So if the audit was initiated by an algorithmic flag or by using AI, your organization has a right to know what flagged it and why.

Most providers never ask.

They just accept the audit as, I don't know, as if it fell from the sky.

But it didn't.

Something was pointed at your practice, and there's a due process argument that you're entitled to understand what it examined.

If nobody has asked for the basis of the audit selection, that is a conversation worth having.