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Medical Billing Audit & Compliance

Coding & Billing Solutions > Medical Billing Audit & Compliance

Medical Billing Audit & Compliance

Is your organization considering conducting a medical billing audit? Coding & Billing Solutions provides a full range of health information management and billing services to hospitals and physician providers, including medical billing audits.

What Is A Medical Billing Audit?

A medical billing audit is a thorough and comprehensive examination and assessment of clinical documentation and the overall medical billing process for a health care provider. This process aims to ensure the effectiveness and reliability of these crucial aspects of healthcare operations.

During a coding and billing audit, a CBS auditor gathers various types of records, including medical records, x-rays, and lab reports, financial records such as entered charges, explanation of benefits (EOBs), and accounts receivable ledger. Additionally, policy-related documentation required by providers or the government is also reviewed. The purpose of a medical billing audit is to meticulously scrutinize the health records maintained by the practice and the medical billing data submitted to payors, with the goal of identifying, monitoring, and rectifying any inappropriate billing practices.

Audits can be conducted in two ways: prospective audits take place before claims are sent to payors, while retrospective audits are conducted after the fact. Some practices follow the approach of conducting prospective audits for new providers and retrospective audits for current providers.

Coding & Billing Solutions specializes in the following types of medical billing and compliance audits:

  • Inpatient Auditing & Compliance
  • Outpatient Auditing & Compliance
  • Physician Auditing & Compliance
  • Pharmacy Coding & Billing Reviews
  • Specialty Areas

Some of the goals of a medical billing audit include:

  • Identifying and correcting errors in medical billing.
  • Maximizing revenue and ensuring proper reimbursements.
  • Improving compliance and avoiding costly penalties.
  • Gaining insights and analytics on billing performance.
  • Increasing transparency in the billing process.

The scope of a medical billing audit is comprehensive and covers all aspects of the medical billing life cycle. This includes insurance verification processes, ICD-10-CM and CPT coding, claim submission, payment posting, follow-up, and denial management processes.

Medical billing audits from CBS offer several advantages:
Coding compliance: Audits help identify and address problematic areas before they are challenged by government authorities or insurance payors. They enable the identification of inaccuracies and provide instructions on how to correct issues. They also build confidence among coding staff and ensure the use of up-to-date procedure and diagnosis codes. Areas requiring staff education and training can be identified to ensure proper coding protocols are followed.

Compliance assurance: Medical claims audits help protect practices against fraudulent billing activities and claims. Audits can identify reimbursement deficiencies and highlight deviations from the national average due to inappropriate coding. They can also reveal opportunities for increased reimbursement, ultimately boosting revenue. Furthermore, audits streamline file processing, reduce improper payments, and optimize claim payments.

Administrative benefits: Medical billing audits benefit administrative staff by confirming the accuracy of claims and their proper submission. Audits establish standards for office staff and create a positive, stable work environment and a culture of compliance that attracts and retains talented personnel. Inappropriate billing practices, such as under- and over-coding, code overuse, and improper unbundling, are replaced with appropriate billing for services and procedures. When policies and procedures are correctly implemented, the likelihood of external audits decreases significantly.

Increased Profitability: Conducting a medical billing audit can enhance a practice’s profitability by identifying inaccurate, incomplete, or inappropriate billing practices that result in financial losses. By examining medical record documentation, unnecessary or unrecorded charges for services or items provided to patients can be discovered and rectified.
Getting Ahead of Potential Problems: Medical billing audits provide coding staff with methods to identify, understand, and rectify problems before they are flagged by government authorities or insurance payors for inappropriate coding. This, in turn, helps improve medical record documentation, leading to increased payments for services provided.

Regular medical billing audits are crucial for practices to assess their effectiveness and efficiency in claims management. Even with the transition to ICD-10 coding in the past, the importance of billing audits in the healthcare sector remains high.
These audits establish standards for administrative staff, alleviating stress and frustration. They also offer protection against fraudulent claims and compliance issues, which is especially important when providing services through Medicare. Additionally, a medical billing audit can help practices avoid substantial fees associated with Medicare reporting errors.
If you are interested in learning more about the medical audit billing process from Coding & Billing Solutions, contact us today.