What is Medical Billing Auditing and Why It Is Significant For Your Healthcare Business? 

By Juliet D'cruz

Often healthcare professionals feel like their medical billing operations are running smoothly when they haven’t seen a recent spike in rejections and they are happy with the practice’s reimbursements. 

However, it is critical for large or small practices to collect every dollar they have earned due to the highly competitive business environment. Moreover, when you don’t pay attention to conducting a periodical medical billing audit, it may impact the optimum performance level of your healthcare organization. 

Consequently, it can undermine the financial viability of your medical practice when you aren’t able to collect revenue on the table. So, it is highly essential to conduct an internal & external billing audit. This will help you to shore up the potential risks and identify weaknesses that are influencing your practice drastically. 

Before going ahead, let’s discuss medical billing auditing and its importance for your business to reach its maximum profitability potential. 

What Is Medical Billing Auditing? 

Like all audits, billing auditing is an organized process of verifying the medical records to assure healthcare providers comply with the recent rules and regulations of the healthcare industry. Therefore, it is a process that ensures accuracy by reviewing and examining documentation of the practice. 

Auditing detects the compliance problems that land you penalties with Medicare and impact your bottom line. This helps you determine, check, and fix any inappropriate, incomplete, inaccurate billing practices. 

Significance Of Medical Billing Auditing 

It provides the critical and systematic analysis to investigate the reliability and effectiveness of the comprehensive documentation including the submitted information to the insurance payer and thoroughly checking all the health records. 

Furthermore, this continuous cycle involves examining medical facilities, comparing practice with the aligning standards, observing the new procedures, and implementing change. It is compulsory to complete this cycle for a successful medical billing auditing.  

Billing Audits Purpose

A billing audit covers all the procedures involved in the billing cycle such as 

  • Accurate capturing of patient demographic data.  
  • Patient eligibility verification.
  • Medical coding.
  • Medical claims processing.
  • Posting payments. 
  • Account receivables recovery management.
  • Claim denial management.  

It identifies those areas that need particular attention for improvements by evaluating medical billing records. At this point, healthcare professionals become able to resolve many concerns like;

  • Provider’s documentation errors. 
  • Problems in payer reimbursement. 
  • Unbundling, under-coding, over-coding, and modifier usage concerns. 
  • Areas of non-compliance to payer rules. 
  • Use of deleted codes, inappropriate or wrong codes, and frequency of such mistakes. 
  • Unintended or intended fraudulent medical billing practices. 
  • Errors in the claim scrubbing process.
  • Errors after claim scrubbing. 

Outsourcing medical billing services help you to access billing audit specialists. They protect your medical facility from penalties as well as fraudulent billing activities. 

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How Can You Benefit From a Medical Billing Audit? 

No matter what the motivation would be, conducting regular billing audits gives you peace of mind. So healthcare professionals can focus on other core competencies of their medical business efficiently.

You become able to find inefficiencies that are costing you huge money. These initial compliance measures in the form of billing audits help you manage compliant and efficient billing practices. 

For example, you can find items and services which weren’t recorded as the charge and rendered to the patients when you have effective medical record documentation. Apart from this, when your management teams frequently use incorrect codes and warrant a higher level of CPT code for the visit, your billing auditing expert discovers it. 

You can have a greater profit margin for your business once your medical record documentation is improved. This is increasingly important if you are providing services through Medicare. 

Payments of Medicare are highly dependent on accurate submission. So, it is necessary to submit the correct quality measures to protect your practice from excessive financial burden. 

Advantages of Medical Billing Auditing

  • Before government and insurance payers challenge incorrect billing. Billing auditing experts help you to identify as well as rectify the problematic issue promptly. They will improve billing accuracy as per the latest rules.
  • Both patients and healthcare providers get affected by unnecessary billing. Thereby, you can prevent this unnecessary medical billing activity by efficient billing auditing. 
  • It provides you maximum opportunities for appropriate reimbursement and also helps to figure out reimbursement deficiencies. 
  • Sometimes wrong billing happens when patients have to bear out-of-pocket expenses due to additional administration rendered. Ultimately, it results in investigations and audits. Healthcare professionals can avoid such problems with accurate billing of documented procedures. 
  • It will provide you with a transparent billing system and enhance reliability. Besides, certified coders know how to use accurate coding efficiently. They stay up-to-date with the latest coding rules. They start with the new coding process and don’t use outdated or incorrect codes for procedures. 
  • Internal and external audits can help you improve revenue cycle management. As medical billing and coding audit specialists determine outliers before large payers find them in their claims software. 
  • Have a streamlined workflow of your medical practice with the integration of efficient practice management and EHR/EMR systems.  
  • Strengthened relationships between insurance companies and healthcare practitioners.

Checklist Of Medical Billing Audit 

This checklist will help you to stay on top of your billing audit:

Phase 1

  • Determine the manpower needed to execute a medical billing audit or outsource your medical billing services to an auditing expert. 
  • Conduct the review by designating someone from your administrative staff or hand over this responsibility to an outsourced billing partner. 
  • Circulate a formal audit plan by writing it up. Utilize innovative billing audit tactics that include review documentation versus what was filled out, selecting a particular number of charts per payer and per provider. 

Phase 2

  • To review the risk areas and troubling trends, investigate your billing reports to detect irregularities by matching them against past performance. 
  • Run E&M frequency reports.
  • Give a detailed reporting about how CPT (Current Procedural Terminology) codes will get reimbursed? 

Phase 3

  • Set targets for improvements once you have had all the required information. 
  • Pursue payers to pay contracted rates on time by making a concerted effort. Or hand over this duty to an outsourced partner. 
  • Develop a plan for dealing with delinquent payers by keeping a follow-up on your A/R.
  • Implement advanced strategies and provide more training to your staff. This will help you discover and address any internal & external problems. 

Phase 4

  • For a successful business, make auditing a regular occurrence for your medical facility. 
  • Make auditing easier by building processes into your medical billing operations like, monitoring net collections and running frequent reports. 

Some Tips for Healthcare Professionals 

While conducting medical billing audits many medical practitioners have their own concerns. So, here are some tips to ensure you are receiving the most of yours. These are the following;

  • Implement a system of accountability and designate a qualified team. 
  • Establish benchmarks for improvement. 
  • Create control for catching and preventing errors. 
  • Consider outsourcing medical billing services. 

With new regulations and market trends, medical billing has become more complicated. Medical practice needs to have a strategic approach to medical coding and billing audits. 

A trusted and reputable firm with detailed practice management knowledge, the right resources, medical billing/coding audit tools can help you recognize audit-inducing problems before they occur and manage all of your claims. 

Healthcare professionals will get great ROI on their audit investment by assembling their medical audit arsenal quickly.  

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