Medical Billing Audit – Worthy Checklist to do

Medical billing and coding auditing is now done by everyone in the healthcare industry. It’s necessary to stay compliant and survive in this highly competitive industry. Healthcare organizations handle a large number of documents, and errors can be costly.

In fact, nearly half of all Medicare claims contain errors. Although Medicare pays the majority of claims without review, there is a chance that your claim will be rejected. Aside from insurance payments, a poor medical billing audit process can have an impact on revenue cycle management and bottom lines. Compliance issues, such as incorrect payments or missing records, can also result in penalties.

As a result, you should know how to prepare for a medical billing audit to avoid such problems. In this article, we’ll go over the steps to get ready and provide a quick healthcare billing audit checklist. You will be ready to implement more effective auditing in your healthcare organization after reading it.

What Is Medical Billing Auditing?

Medical billing auditing is a procedure for examining clinical documentation. It examines a healthcare organization’s records for accuracy, reliability, and effectiveness, as well as billing documents submitted to payers. The audit allows for the detection, monitoring, and correction of improper billing practices.

A medical billing audit is a time-consuming process. Clinical records, financial records, accounting documents, and policy-related documentation are just some of the data sources you’ll have to deal with. As a result, it’s critical to consolidate all data into a single system and organize it properly.

There are several approaches to medical billing auditing. You can conduct an internal healthcare billing audit or hire an outside auditor.

  • Internal audits are carried out by a group of people who work for the audited entity. These are the professionals who conduct audits on a regular basis to ensure that billing practices are transparent and efficient. Internal audits are the best option for medium and large healthcare organizations that can keep auditing staff on staff.
  • External audits necessitate collaboration between healthcare organizations and an external auditing body. It compares billing practices to industry standards to identify and correct any issues. External audits may be more appropriate for small practices that lack the required specialists on staff.

If you’ve never been through a medical billing audit before, here’s how to get ready.

You should take some steps to prepare for a medical billing audit before scheduling one. It will initially improve the quality of your medical billing data and documentation. It will also be simpler to plan the audit.

Here are some tips for preparing for a medical billing audit.

Create clear policies and procedures for auditing

Instruct your team on how to conduct audits and when they should be done. You could, for example, conduct internal audits every quarter and invite an external auditor once a year. Another element to include in your policies is data processing rules.

Ensure that your employees are properly coding and documenting their work

Despite rising EHR adoption rates, clinical coders and other healthcare workers are still involved in record-keeping. You should teach your staff how to handle documentation to avoid errors in coding and billing. It will both prepare them for future audits and improve the order and accuracy of your data sources.

Prepare for routine audits

Regularity is required for healthcare billing audits. As a result, when preparing for your first audit, you should consider the upcoming checks. You should also do scheduling, create templates, and other standard documents in addition to policies and procedures. In the long run, such a comprehensive approach will save you a lot of time.

EHR and billing systems should be implemented

EHR and automated billing software are now essential for healthcare organizations. It is, however, required not only for record management but also for audits. You connect data from the start by using an EHR and integrating it with your billing and other practice management solutions.

As a result, audits become much more straightforward and automated. An auditing team can quickly identify any problems or confirm that everything is in order. As a result, one of the most important steps in preparing for upcoming healthcare billing audits is to invest in quality software.

How to Audit Medical Billing: Step-by-Step Instructions

After you’ve completed your preparation, you can begin a medical billing audit. Providers and payer auditors should agree to record any unsupported or unbilled charges in order to conduct an efficient audit.

Here’s how we go about conducting a medical billing audit:

Determine the scope of the audit

Examine your records and the scope of the upcoming medical billing audit to determine how much time and money you’ll need. You’ll need to figure out how many providers, payers, billers, and coders there are. After that, you’ll see why an auditing team is required for regular and thorough checks.

Assemble a team of external and internal experts to conduct a medical bill audit.

Internal and external audits will almost certainly be required. Before you request a medical bill audit, make sure you find a reliable independent auditor and agree on how to do so. Medical billing audits are performed by independent auditors, who are third-party professionals. They have the necessary experience and always remain objective when evaluating billing processes. Auditors and audit coordinators, according to the American Association of Medical Audit Specialists, must be knowledgeable in the following areas:

  • Health records and other forms of clinical documentation format and content
  • Medical terms, ICD-10-CM, HCPCS, and CPT coding
  • Principles and guidelines for auditing
  • Billing claim forms (UB-04, HCFA 1500), as well as billing procedures

Redistribute responsibilities and plan an audit strategy

It’s time to choose the best strategy once you’ve determined the scope and assembled a team. To maintain objectivity, we recommend selecting a set number of records at random from each provider and payer. You can then review the documentation for the selected records to look for any inconsistencies or errors.

Look into your EHR and billing system’s documentation

This is the most important part. Auditors must now examine billing reports, charges, codes, and other important records. Not sure how to conduct a medical billing audit? Ascertain that the investigation:

  • Examines whether the institution followed the physicians’ treatment plan when providing services.
  • Examines whether the services provided to the patient are documented in the records.
  • Checks to see if the charges on the bills are correct.
  • Compares the results to your contract terms with individual payers to see how CPT codes are reimbursed.
  • Compares previous performance monthly or annually to identify risks or problematic areas.

Accept or contest the audit findings

If any issues are discovered during the audit, you must resolve them as soon as possible. If you disagree with the findings of an audit as a provider, you have 60 days to contest them.

A standard healthcare billing audit procedure can be used to audit medical billing using these steps. Because healthcare checks must be performed on a regular basis, an action plan is beneficial. You can also use the medical billing audit checklist to ensure that all of the important details are covered.

A Checklist for Medical Billing Audits

It’s helpful to use a checklist when conducting a medical billing audit. It will help you stay on track and avoid missing something important.

  • In the EHR system, all patient records have accurate IDs.
  • Biographical information is included in all patient records.
  • The name of the person providing care is listed on each chart.
  • All EHR, billing, and other healthcare management systems entries are timestamped.
  • The EHR, billing, and other healthcare management systems all have legible entries.
  • The medical history in the audited patient records is correct.
  • Important information can be found in the audited patient records (e.g., allergies, adverse drug reactions, alcohol, smoking, or substance abuse)
  • Lab tests are ordered and dated correctly.
  • The treatment plans are in line with the diagnoses.
  • The treatment plans are in line with the diagnoses.
  • Physical examinations are documented in patient records.
  • There is evidence of collaboration between primary care and specialty physicians.
  • Prescriptions and refills are all kept track of.
  • Datasheets for medications are used.
  • All procedures and prescriptions require informed patient consent.
  • There are medical codes for ancillary services.
  • Billing and professional documents both use templates.
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