A structured process called a medical billing audit looks at and assesses the accuracy and dependability of clinical documentation as well as the entire medical billing procedure. This procedure verifies that the practice recognizes, monitors, and corrects improper billing practices by carefully reviewing all medical records kept by the practice and medical billing information supplied to payers.
Clinical records, such as medical records, x-rays, and lab reports, financial records, such as entered charges, explanations of benefits (EOBs), and accounts receivable ledgers, and policy-related documentation as required by providers or the government, may all be requested of the practice during a billing audit.
Audits can be carried out either in the future (prospective) or in the past (retrospective) (retrospective). Some clinics adhere to the standard of completing current provider audits retroactively and new provider audits prospectively.
Examining medical billing in general
Compared to coding audits, medical billing audits take a more thorough approach. All phases of the medical billing life cycle are covered by medical billing audit, including insurance verification procedures, ICD and CPT coding, claim submission procedures, payment posting procedures, follow-up procedures, and rejection management procedures. Medical billing audits focus solely on coding and billing and exclude information on the nature or extent of the patient’s treatment, the need of the procedure, the pricing scheme, and any goods or services provided by the provider.
Medical Billing Audit Benefits
Coding conformity:
Billing audits provide you a chance to find and fix issues before the government or insurance payers object to improper coding. Billing audits can be relied upon to find errors, offer guidance on how to fix problems, instill confidence in the coding team, and guarantee the use of current procedure codes. In order to ensure that the correct coding process is consistently followed, the audit’s participants might identify areas where staff education and training are required.
Administrative advantages:
Medical billing audits help the administrative team by ensuring that claims are submitted appropriately and are truthful and accurate. By fostering a positive, stable work environment and a culture of compliance that draws and keeps exceptional employees, audits set the norm for the office workers and save them unneeded frustration. Under-coding, overuse of codes, and incorrect unbundling practices are replaced by proper invoicing for frequently performed operations that are well-documented. The likelihood of receiving a visit from an external auditor dramatically decreases when policies and processes are put in place and adhered to appropriately.
Ensure adherence:
The practice is safeguarded against erroneous billing and claims through medical claims audits. Billing audits make it simple for clinics to confirm ICD-10-CM compliance and decrease or eliminate improper payments. The audit may find problems with reimbursement and show how the practice differs from the national norm as a result of incorrect coding. As a result, areas for more reimbursement may be revealed, which would improve revenue. Additionally, the practice gains from timely file processing, decreased inappropriate payments, and improved claim payment.
Improved connections with insurance providers:
An additional benefit of a medical claims audit is enhanced communication with payers. Claims that are submitted correctly are valued by payers. Prior to a large payer identifying an issue and requesting an external audit, the practice will be able to discover any outliers through an audit that will expose any anomalies.
Improved patient care:
Audits of medical claims help to provide better patient care. The focus of the entire practice turns to the quality of care given by measuring and monitoring services and processes and training doctors on giving patients with positive medical experiences. Better patient outcomes and a more efficient revenue cycle are the results of improved patient experiences.
External Audits Are Required
Internal audits are performed by auditors within the organization, and external audits are performed by auditors outside the organization. Internal audits are exactly what they sound like—an audit carried out by a team of internal billing and coding personnel. The main advantage of completing audits on a continuous basis is available to larger organizations that may have a dedicated internal audit staff. Regular auditing gives the company information that enables process and accuracy improvement.
However, external audits cannot completely replace internal ones. A yearly independent, external audit should be carried out, even in firms that regularly complete internal audits. In general, small practices may find it helpful to rely on one of the numerous firms that are experts in external audits, particularly if they lack the capacity to carry out regular periodic internal assessments.
It is insufficient to merely get paid back for submitted claims. To prevent inefficiencies or fraud, every revenue cycle operation needs to be carefully audited.
Outsource your healthcare revenue cycle solutions to make your auditing successful, experts can do the process efficiently without losing revenue.
