Spot the Glitches in Your Billing Process with Periodic Medical Billing Audits

3 mn read

Audits at any industry is performed to check for compliance. Compliance to standards, compliance to regulations and compliance to legal norms. And in healthcare finance, medical billing audits make sure that that the bills processed at the health care facility are hundred percent legit, accountable and error free. On the long run, auditing is that necessary process which can tweak you practice management and revenue cycle to the next level of efficiency. Monitoring and auditing function is the crux of all effective compliance programs conducted these days. Let’s look into the specifics of the process.

Audits can be

·         Internal


·       External

Internal auditing

It can be a day-to-day process of assessing how effective is your billing system regarding compliance. constant review is conducted on how your billing cycle is running front end and back end to look for any red flags present, to identify neglected areas of operation which could pile up in the future if left ignored. The process can be changed and improved right there when gaps are discovered.

External auditing

It is important to hold independent audits performed by external services to look at your process objectively. Experts in the field can shed light into the risk areas in your documentation, billing and coding practices based on compliance. More often there seems to have risky areas requiring further inquiry and straightening up.

With the internal monitoring process and periodic external auditing conducted, almost all of the impending issues can be caught on time allowing to shape up your billing process. Enables your facility thereby, to withstand the inquiries conducted by the state or private insurance payors from time to time regarding excessive billing or coding compliances. The goal is to pull back any data regarding collection of over payment or underpayment in that case.

Post-payment third party reviews

It is the review conducted by private payers or government. They conduct audits from time to time to make sure all the details listed in the health records validates the claim data. It can be a recovery audit for missing information’s as well. Audits can function as a certain quality assurance for treatment plan is well to gauge the quality of health plans offered while negotiating contracts with the providers.

It has high level legal implications in eliminating health care frauds, abuses and wastage. Which is why providers should pay more attention to medical billing audit process. A notice on government audit usually means your documentation process is being scrutinized, may be due to a complaint filed at the higher-level regarding payment or a HIPPA violation issues. It could be even a relevant date missing or a serious error due to lack of expertise from the staff. It could be a wrong document sent or the document lacked signature of the respective authority. Some test results might be missing or there was failure to document the time when a code was time driven.

Chances are there for improper or inaccurate coding and documentation when the staff are not trained enough to make the best of the electronic medical recording system. An inexperienced staff member could accidently delete or remove data from patient visit entirely or same data might get billed twice. Mistake is gross in both cases and if caught in audit, the facility will be charged penalty and there is loss of trust and reputation. These are considered as potential fraud in claim process. Cannot stress enough on educating the staff on billing software as well as installing security measures to the health records database.

How to avoid risky situations leading to government audit?

With appropriate documentation methods and correct encoding based on industry guidelines, providers can mitigate the risks of getting into trouble for noncompliance. But it requires a lot of effort and focus considering from operational standpoints. It is very important that you appoint the right people for medical billing audit.

Billing process needs constant updating to stay above all risks and challenges. Pay attention to the data in hand and set your benchmark through thorough analysis of the revenue cycle at your clinic. Training your staff at the time of hiring alone will not work to stay complaint to the new billing policies. It should be a continuous process of education for them, since the coding practices keeps getting revised.

Facilities these days designate or hire educators to train the staff on proper use of the software, compliance protocols, billing criterions and coding ethics. And the training should be an ongoing process. Professional billing companies go one step ahead and appoint compliance managers who are compliance-trained professionals to oversee training and education programs for the coders.

Keep in mind that it is always the ownership of the facility held accountable for the risks and issues mentioned above. There is big money and your reputation at stake. Medical billing audit when internally conducted from time to time is an eye opener to ensure the staff are up to date on the new coding regulations, best practice methods and an optimized documentation process.

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