There is no question that various changes in government have caused health care organizations to carefully examine their billing auditing and claims processing Medical Billing Services. This has also led to the importance of medical billing audits increasing significantly.
Each practice should have a strong understanding of not only the nature of billing audits, but also the types that best suit its individual needs. If you don’t have a strong understanding of billing practices, weaknesses, and growth opportunities in your practice, it might be time for a refresher.
What is a billing audit?
The billing audit is an organized process that examines and evaluates the effectiveness and reliability of the clinical documentation contained in the health records maintained by the provider entities and the medical billing data presented to the payers to ensure that it is identified, monitored and rectified. Improper billing practices, which will not only benefit your bottom line, but also highlight potential compliance issues.
Data sources for conducting the billing audit would include all or part of the following:
-Clinics (for example, medical records, documentation such as consultations, X-rays and laboratory reports)
-Financial (for example, documentation of receipt of payment, such as charge sheets from the main office, remittance notices and accounts receivable books).
Policy-related (for example, documentation related to areas such as provider-specific policies (regarding follow-ups, patient collections, appeals, etc.), government policies, memos, and bulletins).
Audits can be performed before claims are sent to payers (prospective) or after the fact (retrospective). In some practices, all new supplier audits are conducted prospectively, while current supplier audits are conducted retrospectively.
Scope of billing audits
Billing Audits should cover all areas of the medical billing life cycle, starting with the insurance verification processes, claims submission process, payment posting process, monitoring processes and management processes.
Billing audits – Exclusions
Billing audits are relatively specific and do not include:
Level or scope of care, pricing structure, or items and services provided by vendors.
These issues can be reviewed in other ways and providers and payers should have mechanisms in place that involve appropriately qualified personnel to address them.
Benefits of billing audits
There are a number of compelling reasons why auditing is really beneficial. These benefits cover coding, clinical practice, and administration.
• Identify and correct trouble spots before the government or insurance payers challenge inappropriate coding again.
• Building trust among coding staff
• End the use of outdated and incorrect procedure codes
• Establish staff education and training standards that support future changes
Administrative Benefits
• Make sure claims are filed correctly
• Determine outliers before large payers identify them in their claims software (and request an external audit)
• Protection against fraudulent claims and billing activities
• Reduce and even prevent incorrect payments
• Reveal if your practice varies from national averages due to insufficient documentation, loss of income, or inappropriate coding.
• Remedy undercoding, overuse of codes, inappropriate unbundling habits, and encourage proper billing of documented procedures
• Save unnecessary frustration for your staff
• Ensure that claims are presented accurately, improving the relationship between you and your payers.
• Establish standards for staff and improve various practices
• Reduce the possibility of an external audit
• Create a strong culture of compliance
• Accelerate and optimize the adequate payment of claims
• Improve the financial health of the practice, creating more stability for its staff
Clinical benefits
• Improve patient care
• Greater attention to quality of care
• Follow-up and monitoring of the use of services and procedures
• Educating physicians about the entire patient experience
• Improving care through high-level analysis of the types of procedures offered
• A smoother income cycle that has been linked to a better financial experience for patients already better patient outcomes.
In general, conducting billing audits helps the practice understand risk and serves as a starting point to work toward smooth workflows and the best possible operating practice.