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Home  /  Our Blog   /  Why You Should Conduct Medical Billing Audit

Why You Should Conduct Medical Billing Audit

Medical billing audit is a planned process that evaluates whole medical billing and clinical documentation for reliability and efficiency. In medical billing audit, all healthcare data is analyzed and medical data provided to insurance is also evaluated. This helps in monitoring, identifying, and correcting any malpractice or inappropriate medical activity.

During medical billing audits, clinical records such as medical reports, lab reports, X-rays, and medical records are demanded. Financial records such as accounts receivable ledger, EOBs, entered charges are demanded by the Government or the audit company.

Audits can be conducted before or after the claims are sent to the payers.

Types of Medical Billing Audit​

There are two main types of medical billing audits.

1: Internal Medical Billing Audit:​

An internal audit is conducted by the medical billing staff. Large healthcare organizations have a dedicated team in place for internal audit purposes. However, having a dedicated audit team in-house is expensive for small practices.

2: External Medical Billing Audit:​

An external medical audit is performed by a third party like an insurance company or government. The external medical audit services are hired by small practices as they cannot afford to have an internal audit team.

Apart from these two audits, there are three audits such as:

4: Random Audit:​

The random medical audit is the most commonly used audit type used by healthcare organizations. It is not scheduled before and done on an ad-hoc basis. It tells the auditors whether a detailed audit is necessary. They look at the random samples of submitted claims. To determine if the organization is working as per rules and regulations.

5: Comprehensive Audit:​

In a comprehensive audit, the specific claims are selected to be audited on a deeper level. This audit type is particularly helpful when claims are in dispute and the involved party is looking for a refund on the claims.

6: Hybrid Audit:​

A hybrid audit combines the features of both random audits as well as comprehensive audits. This leads to more accurate statistics regarding claims and works best for recovering the overly spent money.

Need for External Audits​

The medical audit conducted by the internal team and external team is known as internal audit and external audit respectively. An internal audit is conducted by the internal medical billing team. Large organizations have dedicated internal teams for medical audit purposes. However, small practices may find it beneficial to outsource their medical audit to specialized external audit companies. The external team doesn’t have a conflict of interest and gives suggestions regardless of the impact on revenue.

Regular internal audits can provide data that will help in improving the process. However, it can be costly to have frequent medical audits. For this purpose, small healthcare practices can hire an external audit team to conduct a thorough audit once a year.

Importance of Medical Audit​

A medical audit is really important for the proper functioning of the healthcare organization. It results in proper documentation of medical records. The best way to achieve complete and correct documentation is only possible by conducting a billing audit. A medical auditor points out the facets in which medical staff needs to improve. This convinces the organization in training its staff the right way.

Advantages of Medical Audit​

There are various benefits of conducting a medical audit. Some of the most important ones are mentioned below:

1. Medical Billing Compliance:​

One of the biggest reasons medical billing audits are conducted is to ensure compliance with various coding standards and HIPAA. HIPAA compliance is the most crucial one, violating which can cause serious problems for your practice. Besides HIPPA, medical audit verifies compliance with ICD-10-CM, the widely accepted coding standard. Through the medical audits, the practice is secured against fraudulent billing and coding activities.

Through the medical audit, inefficiencies in the data are identified, corrections are made and the use of up-to-date coding procedures are ensured. The medical auditor mentions the need to train staff on medical coding and billing procedures for better work efficiency.

2. Streamlined Workflow:​

Various policies and procedures are implemented during medical billing audits. Medical audit results in a streamlined workflow which in turn helps create a positive environment for talented employees to thrive. A clean medical audit boosts productivity, time management, communication among the team members, and cost-efficiency.

3. Better Relationship With The Insurance Company:​

Healthcare practices try to have stable relationships with payers. Insurance companies appreciate when accurate claims are submitted because it saves their time. A medical billing audit helps in generating cleaner claims by identifying potential problems and inaccuracies in the data. A better business relationship between the healthcare practice/billing company and payer is established when correct claims are submitted to the insurance agency.

4. Administrative Benefits:​

Medical billing audit lifts off the unnecessary burden from Unhealthy habits like under coding and code overuse are replaced with proper billing for common documentation procedures. When proper policies and procedures are implemented in the practice, a stable and positive working environment is created which leads to better performance by the staff members.

The Medical Billing Audit Checklist​

I have assembled this medical billing audit checklist which will help you in getting prepared for a medical audit without losing important information.

  • Make sure all patients have correct
  • Correct biographical data of the patients are recorded
  • The Care provider name is mentioned on the chart
  • All entries are dated correctly
  • All entries are legible
  • Appropriate medical history of the patients
  • Important details are recorded
  • Lab tests are organized properly and dated as well
  • Consistent treatment plan with the diagnoses
  • Physical examination history
  • Medication data sheets are used
  • Interaction between primary and specialty physicians is recorded
  • All prescriptions are recorded
  • All canceled procedures are recorded
  • Written patient consent is recorded
  • Right medical codes are assigned
  • Templates for billing and professional documents

Medical Billing Audit Companies​

There are various medical billing audit companies in the market. Medmax Technologies Inc is one of the best medical billing audit companies, serving healthcare providers for over a decade. We believe in a human approach to medical billing and collaborate with our providers to make their practices more profitable over time.

Conclusion​

Keeping in view the importance and benefits of a medical audit, it is absolutely obvious why your practice needs to conduct a medical billing audit. If you want more profitability by submitting accurate claims and receiving fewer denials, it is high time that you consider conducting a medical billing audit.

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