Medical Billing Audit Services. A Comprehensive Guide

Medical billing auditing is a systematic process that checks and assesses the effectiveness and dependability of clinical documentation. This procedure ensures that the practice recognizes, monitors, and corrects improper billing practices by carefully reviewing all medical records kept by the practice and medical billing information given to payers. Because billing factors have an impact on revenue, it’s crucial to identify any potential compliance problems.

Medical Billing Audit Types:

Medical practices can audit medical bills in a number of ways that are both efficient and effective. The main categories of medical audit are listed below.

Internal Audit:

Internal billing audit services ensure that claims and payments are processed legally and correctly. The greatest approach to prevent healthcare fraud is to routinely audit internal regulations and practices. Furthermore, because healthcare crimes entail an element of intent, it gives a powerful defense against any charges of such crimes.

External Audit:

This audit is being carried out by outside experts that are proficient and educated in billing audits. They offer a frank assessment of a practice’s billing procedures. One advantage of an external billing audit is that conflicts of interest that could threaten the doctor or internal staff are less likely to occur. Additionally, it liberates the practice of working alone.

Scope of medical billing Audit:

The medical billing life cycle is covered in detail by billing audits, which are far more thorough than coding audits and start with insurance verification procedures, ICD and CPT coding , payment posting procedures, claim submission procedures, follow-up procedures, and denial management procedures.

Medical Billing Audit Process:

Planning and carrying out a medical billing audit carefully is necessary. There are 4 main steps in the entire procedure, which are covered below:

  • Check the Audit Scope:

There are other options, such as a hybrid audit, a full audit, and a random audit. Random audits choose significant and insignificant claims based on their dollar worth. A successful audit carefully reviews the audited claims, placing special emphasis on requesting refunds. The hybrid audit combines the random and thorough audit procedures to evaluate samples of all claim categories to look for gaps. Before choosing the scope of the audit and the number of claims to review, practice should make sure that it has the appropriate resources and support.

  • Establish the sample size:

The audit sample’s patient encounters should include a certain proportion of each encounter type. If you audit too many papers, it will be expensive and time-consuming, and if you audit too few, the results may be skewed. It is common to use 10 to 15 charts as the audit sample size. When conducting an audit involving numerous physicians, the OIG suggests using five to ten charts per medical provider using RAT-STATS for statistical sampling. Practices can comprehend how clients use sample approaches by using tools like RAT-STATS. This enables the practice to gather data highlighting risk areas and maintain an active approach to compliance procedures. If the practice is aware of these areas, examines the paperwork and coding, and provides guidance based on variances, the likelihood that a payer audit may uncover hidden liabilities will be decreased.

  • Gather Information.

Practices must gather data necessary to establish the date of service (DOS) for the charts under examination once the sample size and charts have been decided. Lab results, paperwork, photographs, and other supporting items might be included in the medical record for the patient encounter. All supporting paperwork is required in order to effectively complete the examination. A retrospective audit needs the superbill/charge ticket, patient chart, claim form or billing record (to confirm what was submitted), explanation of benefits (EOB) or Remittance Advice—for each patient interaction. You may also want to familiarize yourself with the format of the chart and any special forms, such as the history form, problem list, and prescription sheet.

  • Conduct the audit:

Utilize your resources and tools to carry out the audit. Examine the documentation and the coding. Verify coding requirements for offerings like:

  • New versus returning patients.
  •  consultation versus referral.
  • time-based coding conditions.
  • services for emergency medical care.
  • Hospitals and non-physician practitioner services.
  • Examine audit results:

Analyze your findings when the audit is finished to pinpoint any issues, such as:

  • incorrectly designating operations or services with CPT or HCPCS Level II codes.
  • E/M levels are not documented.
  • Incorrect diagnosis codes
  • insufficient or inappropriate use of modifiers.
  • the wrong diagnosis and linkage.
  • services rendered but not paid for.

Billing Audit Services

  • Form the Audit Report.

Compile the medical billing audit services results into a concise report. You should write convincingly and thoroughly. The scope and methods of the audit should be clear to the reader. Find out how many contacts were correctly and mistakenly recorded. Finally, suggest some corrective actions. It is possible to recommend more instructions or adjustments to the documentation procedures. Include recommendations for further research to ascertain whether the disciplinary action was successful.

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