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Medical Billing Audit Process

What You Need To Know About Medical Billing Audit Process?

Medical Billing Auditing

Performing regular medical billing audits is vital for a practice to determine its claim performance and efficiency. Medical billing auditing is a planned process of analyzing and evaluating the effectiveness and dependability of clinical documentation and the overall medical billing process. This procedure thoroughly examines all health records kept by the practice and reviews medical billing data submitted to payers to ensure that the practice identifies, supervises, and adjusts improper billing practices.

During a medical billing audit, providers or the government may request clinical notes such as lab results and medical records, as well as financial records such as payment schedules, charge sheets, policy-related files, and so on.

Medical Billing Auditor

A medical billing auditor should perform internal or external audits of coding accuracy, regulations, and processes to ensure that the organization operates efficiently and legally. Medical coding, medical terminology, clinical information, compliance, and regulatory standards must all be known to the auditor. Furthermore, the auditor must be able to identify the scope of an audit, conduct the audit using approved tools, compile the data, report the findings, and provide corrective suggestions and employee training.

Most medical auditors have extensive training and are experienced, medical coders. Auditors may work for an insurance company, a government organization or contractor, or healthcare professional. Auditors play an essential role in the financial achievement of the company in the last place of work by:

  • Minimizing claim denials as a result of incorrect coding or inadequate documentation.
  • Identifying outliers before payers request an internal audit from the practice.
  • Disclosing differences from national averages due to incorrect coding.
  • Avoiding a RAC audit or requests from federal contractors for medical record documentation.
  • Ensure appropriate paperwork that supports reported services and procedures.
  • Detect extra payments and prevent false claims obligations. 
  • Recognize reimbursement inadequacies.

After completing a successful medical coding audit, the auditor can share information on resolving non-compliant billing tasks. As a result, the provider and staff are capable of protecting patients and achieving maximum repayment without fear of consequences.

Medical Billing Audit Process

  • Identify the audit’s scope and resources required to complete it effectively and successfully. This audit may include determining the clinical staff, payer mix, and billing and coding staff pattern.
  • Analyzing auditing scene to identify problematic patterns or areas of higher risk. An audit also includes determining the frequency with which providers provide services and analyzing CPT code usage by billing staff and providers.
Medical Audit Process
  • Corrective action is being taken by using audit reports as strategic knowledge to enhance revenue cycle management and quality care. That involves establishing achievable improvement goals, tackling internal issues that have been identified, and forcing payers to strengthen any areas where they have been discovered to be insufficient.
  • Discovering and repeating the process to make future audits simpler and more accessible.

These steps comprise a standard healthcare billing audit approach that you can use for medical billing auditing. Since healthcare verification must be performed regularly, an action plan is recommended. You can also use the medical billing audit checklist below to ensure that all required aspects are checked.

Medical Billing Audit Template

Doctor’s offices, hospitals, and other healthcare providers use a medical billing template to show patients the costs of medical visits. The audit templates have the same basic layout and have been partially completed, exhibiting the process of planning and completing a specific clinical audit step by step. These templates focus on methodology, assisting you in selecting a topic, and ensuring audit activities are carried out efficiently and with the most significant benefit to patient care.

Tools For Medical Auditing

For auditing a health record, an effective audit tool is essential. A surgical audit tool should be used, for example, if the auditor is reviewing surgical notes. The tool should represent the practitioner’s rules if the auditor performs an evaluation and management (E/M) audit. Some auditors use audit software to audit documents, generate reports, and assist with data analysis. Remember that computer software cannot determine medical necessity. That is a “thinking” process that necessitates the auditor’s extensive knowledge of medical coding. 

When choosing an audit tool, remember that tools differ between payers. MAC tools may also vary. When appropriate, the auditor should select a payer- or Mac-specific tool based on the audit scope.

It is also critical to have references on hand. The auditor should refer to the relevant documents for accuracy and back up audit findings with provable guidelines:

  • Guidelines for Evaluation and Management Documentation and current CPT guidelines.
  • Use ICD-10-CM, CPT, and HCPCS Level II code sets for auditing outpatient organizations.
  • AHA Coding Clinic and CPT Assistant references.
  • Physician frequency reports and specialty utilization.
  • Payment policies and guidelines.
  • Reference to medical terminology.
  • OIG Work Plan

Medical Billing Checklist

Using a checklist during a medical billing audit is essential. It will assist you in staying on track and prevents you from losing something.

  • All patient records have valid IDs.
  • All patient records contain the necessary biographical information.
  • The name of the caregiver includes in each chart.
  • Accurate medical history contains audited patient records.
  • Physical examinations have been documented in patient records.
  • Collaboration evidence between primary care and specialty care physicians.
  • Every medication and refill is documented.
  • Medication information sheets are used.
  • All missed or cancelled procedures are documented.
  • Correctly assigned and formatted medical codes.
  • Medical codes for ancillary services.
  • Use templates for billing documents.
Medical Billing Checklist

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