A medical billing audit is necessary for all healthcare providers to help reduce and catch errors that could lead to denied claims, revenue leakage, investigations, and, most importantly, lost or unhappy patients.
This short blog explains what medical billing audits are, who conducts them, how to improve your current audit process, and how they can benefit your medical practice.
A medical billing audit analyzes the efficiency of a provider’s clinical documentation and medical billing process. It checks all the health records kept by a medical practice and looks at the billing info sent to insurance companies and payers. This makes sure the practice is dealing with billing mistakes and fixing them. Since billing is tied to profits, spotting and correcting mistakes prevents your practice from losing revenue and reputation with payers. These audits can happen before sending claims (prospective) or after (retrospective).
Medical billing audits can be done by the practice itself to improve things or by an outside group to make sure the practice is doing things properly. During an audit, the practice might need to share clinical records like medical files, X-rays, and lab results; financial records like accounts receivables and charge sheets; and documents that show the practice’s policies. However, external audits don’t replace internal audits completely. Doing a separate outside audit every year is also useful for bigger providers that perform regular internal audits.
Besides an internal medical billing department, there are several organizations and entities that perform audits in the U.S. healthcare system to ensure that coding, billing, legal, and ethical standards are followed. These include:
Centers for Medicare & Medicaid Services (CMS): CMS is a federal agency within the U.S. Department of Health and Human Services that administers Medicare and Medicaid programs. It conducts audits to ensure that healthcare providers participating in these programs adhere to regulations and guidelines.
Office of Inspector General (OIG): The OIG is an independent agency within the U.S. Department of Health and Human Services responsible for investigating fraud, waste, and abuse in federal healthcare programs. It conducts audits and inspections to identify non-compliance and unethical practices.
Private Insurance Companies: Insurance companies that provide health coverage often conduct audits of healthcare providers to ensure that the services billed are accurate, medically necessary, and compliant with the terms of the insurance policy.
State Health Departments: State health departments may perform audits to ensure compliance with state regulations and standards in healthcare facilities, including hospitals, clinics, and long-term care facilities.
Accreditation Organizations: Organizations like The Joint Commission (TJC) and the Healthcare Facilities Accreditation Program (HFAP) conduct audits to assess the quality and safety of healthcare facilities. Their focus is on ensuring that facilities meet certain standards to maintain accreditation.
Medical Billing Partners: Medical billing companies specializing in conducting audits and assessments can help healthcare providers comply with regulations, ethical standards, and best practices while having enough time to look after patients.
State Medical Boards: State medical boards oversee the practice of medicine within their jurisdictions. They may conduct audits or investigations if there are concerns about a healthcare provider’s ethical or legal conduct.
You can improve your internal medical billing audit process by performing daily and weekly checks and using a checklist based on your practice’s specialty. The basic checklist should include:
If your medical practice is struggling with medical billing audits, contact Hansei Solutions. Our medical billing team can analyze your practice’s medical billing process, identify room for improvement, and implement data-backed solutions that drive growth and revenue. Don’t let your practice slip into bad debt because of undereducated or novice medical billing companies. Call Hansei Solutions to learn about our years of experience helping non-hospital and behavioral facilities focus on patients and not bills.
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