Medical Billing is a comprehensive and complicated process and should handle precisely at all levels and scopes of service.
At each scope quality standards must be evaluated to ensure that they meet the maximum reimbursement criteria.
For smooth and profitable healthcare revenue cycle solutions, medical billing auditing is required for each scope of service.
Understanding the significance of medical billing auditing involvement at the appropriate time can save many claims from denials and revenue loss.
Let’s talk about medical billing audits which can help you improve your financial system for your medical billing.
Medical billing revenue flow is maintained by quality claims, ensuring that the quality percentage does not fall under the standard margin.
About Medical Billing Audit
Medical Records and Documentation
Examine the patient records to ensure the accuracy and completeness of the information provided to maximize the collections. Precise documentation is required for billing and coding functions.
Coding errors are unavoidable regardless of specialty or level of complexity. The inclusion of new coders or new specialties may require attention and frequent audits based on the error percentage, and any changes in the coding guidelines.
Check the Codes
Confirm that the procedure code CPT, diagnosis code ICD-10, and modifiers are correct for the given medical records.
Coding diagnosis vs. Symptoms
Primary and secondary coding levels and code first or combo code guidelines are just a few examples of areas that should be double-checked, to make sure they’re not the source of denials.
Charges and Fee Schedule
Auditing your charge entry process on a regular basis should be a requirement to ensure you are being paid in accordance with the fee schedule.
Being unaware of changes in the fee schedule and billing claims with outdated values can have a serious impact on your financial system.
Claims duplication is a common cause of denials and rejections. To avoid such scenarios, and reduce possible reimbursement, medical billing audits should focus on verifying claim duplications.
Medical Billing Audits
Unlike medical coding and medical billing audit can cover the entire billing scope of services throughout the RCM cycle.
The following is a list of billing scopes that require regular audits to ensure clean claims and faster payments:
- Procedure for Insurance Verification
- Entry of Demographic Information
- Procedure for submitting a claim
- Posting Payments
- Follow-up on outstanding invoices and Denial Management
The Advantages of Billing Audits
Auditing may appear to be a luxury, especially in a busy practice, but it is actually beneficial.
These advantages include coding, clinical practice, administration, etc.
1. Benefits of Coding
Billing audits are beneficial to coding staff because they allow them to identify and resolve the problem areas before the government or insurance payers raise objections to improper coding.
Having someone to rely on the spot the errors, and give instructions on how to fix them with the medical coding, ensures that they use the most up-to-date procedure codes.
2. Benefits of Administration
Medical billing audits benefit the administrative staff by ensuring that claims are true and accurate.
Also, it will check whether they are submitted properly or not.
By creating a positive, stable work environment and a culture of compliance that attracts and retains talented personnel, audits. It can set up the standard for office staff and save them from unnecessary frustration.
Medical claim audits can protect your practice from fraudulent billing and claims through medical claims audits.
Practices can easily verify compliance with ICD-10 and EHR when they have an internal check and balance system in place.
3. Clinical Advantages
Medical claims audits help you to improve patient care in a positive way. The focus of the entire practice shifts to the quality of care provided by tracking and monitoring services and procedures, towards educating physicians as well. And also you can find how to provide positive medical experiences to their patients.
When patients have a better experience, the revenue cycle runs more smoothly, and patients have better outcomes.
Overall billing audits aid a practice’s understanding of risk and serves as an initial step for improving workflows and achieving the best-functioning practice possible.
Internal Billing Audits vs. External Billing Audits
Medical billing audits are sometimes more important than the type of audit. Here a few of the benefits are:
Benefits of Internal Billing Audits
Internal audits are exactly what they sound like an audit conducted by an internal team within an organization.
Larger companies may have a dedicated internal audit team to do it. It gives them the advantage of performing audits on a regular basis.
Auditing on a regular basis provides the organization with data that allows for continuous process and accuracy improvement.
The audit may reveal reimbursement issues that differ from the practices due to coding errors.
Benefits of External Billing Audits
For small practices, external audits can be a great option. It provides insights that eliminate conflicts of interest and detect upcoming without revenue impact, which is even the internal auditors might miss.
There’s also the advantage of recommendations having more weight when they come from a third party.
On other hand, external audits aren’t a perfect substitute for internal audits.
Even organizations that conduct internal audits on a regular basis, it should be independent.
Also the external audit can done once in a year
Medical Billing Audit Workflow
Medical billing audits will look at the following processes:
- Identifying the audit’s scope and the resources required to complete it in a timely and efficient manner. This audit may include understanding the clinical staff involved, payer mix, billing, and coding staff.
- Examining the auditing scene to identify any problematic trends or areas of increased risk.
- Auditing the frequency of provider services and analyzing CPT code usage by billing staff and providers.
- Setting improvement goals, addressing internal issues that have been identified, and pressuring payers to improve any areas are all part of this process.
- Taking proper action by utilizing audit findings as strategic data to improve revenue cycle management and patient outcomes.
- Learning and repeating the process in order to make future audits simpler and more straightforward.