A domestic medical coding and billing audit is an operation that inspects and estimates the value and dependability of clinical documentation and the overall medical billing process. This technique closely examines health records uphold by the practice and evaluates medical billing data presented to the payers to make sure that the practice picks out, observes and rectifies unprofessional billing practices.
During a coding and billing audit, the auditor usually gathers various types of documentation. These can incorporate clinical records like medical records, x-rays, and lab reports, also financial records like entered charges, explanation of benefits (EOBs), and accounts receivable ledger. As well, policy-related documentation can also be essential by providers or the government and may be accumulated by the auditor as well.
An audit can be finalized in two ways – either prior to claims submission to payers (prospective) or later the claims have been prepared (retrospective). Sometimes, certain practices may select to perform audits eventually for new providers, while current provider inspects may be managed retrospectively as per their internal policies.
Scope of Medical Billing Audit
When matched up to Medical coding audits, medical billing audits usually have a wide scope. This is because medical billing audits surround all features of the medical billing life cycle, starting with insurance verification procedures and expanding to ICD-10-CM and CPT coding, claim submission, payment posting, follow-up, and denial management processes.
Advantages of Medical Billing Audit
Billing audits provide a manner of encountering and labeling possible issues prior to being challenged by insurance payers or the government for unsuitable coding practices. Depending on billing audits can aid in picking out inaccuracies, dispensing advice on rectifying any issues, implanting trust among the coding team, and making sure the use of current procedure and diagnosis codes. Those who perform the audit may also recognize areas that need extra staff training and education to make sure adherence to the right coding protocols.
Medical billing audits can be beneficial for administrative staff as they help to confirm the accuracy and authenticity of claims that are submitted correctly. Audits also establish a standard for office staff, creating a positive and stable work environment that promotes compliance and attracts and retains skilled personnel. Down the audit process, under- and over-coding, code overworked, and inappropriate unbundling practices can be replaced with appropriate billing practices for services and procedures. By implementing and adhering to policies and procedures correctly, the likelihood of external audits is significantly reduced.
Medical claims audits can help practices in defending themselves against fraudulent billing activities and claims. The audit process may help to recognize reimbursement deficiencies and spotlight instances where the practice varies from the national average due to unsuitable coding. Opportunities for increased reimbursement may also be revealed, resulting in a boost in revenue. Furthermore, efficient file processing and a reduction in improper payments can be achieved, leading to optimized claim payments and added benefits for the practice.