A medical billing audit is a structured assessment of compliance and quality at a healthcare facility. Each procedure that results in a claim being billed is examined to ensure that it complies with all relevant federal, state, and private insurance company standards. Action resulting in a claim’s billing is reviewed for compliance with all applicable federal, state, and personal insurance company requirements. The audit process covers every business area, but the reimbursement process is the essential item on the medical billing audit checklist.
The objective of a medical billing audit checklist is to withstand ongoing examination by federal auditors and insured contractors. Implementing scheduled audits is the most vigorous defence against government and insurance company audits at the healthcare facility. By evaluating the claim data and generating risk reports, any suspicious billing trends can be found, allowing healthcare facilities to detect their compliance oversights. If not, the physician may incur high costs due to federal prosecution, financial fines, criminal penalties, exclusion from insurance networks, and requests for reimbursement returns.
The medical billing audit is expected to guarantee that the facilities deliver high-quality patient care and that the providers are informed about documentation requirements. A successful medical billing audit checklist can thoroughly examine the facility’s revenue cycle management and optimize it to ensure that the correct payment is made for each treatment. Additionally, it allows you to defend yourself against malpractice lawsuits, health plan denials and audits from public and commercial insurance providers.
Using the right tools, following a medical billing audit checklist, determining the audit’s precise scope, reporting the audit results, offering suggestions for fixing problems, and training personnel are all things Practolytics can assist you with. The auditors at Practolytics may assist you in resolving an ongoing non-compliant billing procedure at the facility by conducting a successful audit. You and your team would then be able to protect your patients, get the proper reimbursements, and stay clear of payment litigation risks.
An overview of auditing any healthcare service is provided in the list below. It helps to have a thorough medical billing audit checklist to get all the necessary details when evaluating your business. It is suggested that you create a unique index based on the demands of your practice’s specialties. Let’s examine each item on the list in greater detail:
Verifying patient IDs and authorizations must be included in the medical billing audit checklist you create. The information is recorded on the demographic chart.
Additionally, confirming that the patient’s insurance plan was active and valid on the day of service listed in the documents is crucial. The demographic and other claim information should be carefully compared to the patient’s report found in the medical records; sometimes, names are switched accidentally.
It is essential to look into the information of the provider who provided the service and the provider who issued the bills. It is imperative to confirm that the provider named in the documents has the appropriate licenses and credentials according to state regulations. Verify that the document is correctly signed and authorized, when needed, by the right supplier.
It is also essential to check the codes and bills and the history of paid and refused claims from this healthcare provider for the same service date. It is necessary to determine which regulations were born and which were denied in the prior allegations and if the records submitted in the earlier claim were identical to those offered in the present claim or if new records were available. Has the service provider divided the bills for the exact service date into multiple shares? These things need to be examined in the audit.
Examine the information for clarity and completeness, confirm that the past medical history is recorded appropriately, and ensure that it includes information on allergies, drug and food interactions, and smoking, among other things, according to the medical record audit checklist. Cross-check the IDs in all records.
Check that all records of patient encounters, doctor examinations, and follow-up visits preserve the proper chronology. Medical billing checklists emphasize clear and thorough documentation of all primary care physician findings—complete with a summary of all the patient’s reported health issues.
If the recorded records show continuity and coordination of services offered by primary care physicians and speciality specialists, every detail from referrals to other departments should be present and checked. About speciality consultations, the date of service, provider details, and a description of the visit should all be included.
It is necessary to document and confirm that requests for radiological tests, blood tests, and other procedures are appropriate for the conditions associated with the suspected disease. All laboratory findings must have accurate dates and government approvals. According to the medical coding, medical billing, and medical auditing aapc, the radiological reports need to be finished with the interpretation of the image included and properly authorized by the provider who interpreted the result.
The final diagnosis and disease condition details serve as the basis for the treatment plan, so they are the central focus of the medical billing audit checklist. To ensure that everything is in order, these should concur with the findings of the primary care physician. It is critical to check if the treatment plans were in line with the diagnoses and whether the lab results, imaging and scan reports, speciality consultant summaries, and other papers were documented alongside them.
Every record of the dates and types of procedures performed, the provider’s information, the material list, and the quantities utilized for the system must be examined. Details regarding informed permission must be recorded and approved by the patient, bystander, and relevant practitioner without fail, according to the medical billing audit checklist. It should be verified that the documents provide the patient’s immunization history and information on any previously scheduled appointments that were postponed or cancelled.
All records of medicine prescriptions and refills should be included in the documents. Verify whether the patient’s medical records have a valid prescription from the ordering physician. Additionally, medication datasheets that are appropriately categorized according to the division and provider giving the drug should be included. Verify that there is sufficient documentation about post-procedure patient education and follow-up instructions.
The most crucial component of medical billing checklists is verifying billing documents for coding compliance. Regarding code, many specifics need to be carefully examined. Always verify that the claim’s CPT/ICD codes are correct. Additionally, confirm that the diagnostic codes used are of the highest specificity feasible based on the medical records and that the regulations issued in the claim correspond with electronic health reports.
The most important item on the medical billing audit is the verification of the coding procedure. When using modifiers in coding, it is essential to consider whether the number of units billed is accurate and whether the proper codes are for a single or several teams. Ensure the medical billing services use the appropriate procedure and ancillary service codes. Additionally, check to see if processes were followed to avoid potential risk factors such as unlisted codes, incorrect coding, service unbundling, upcoding, etc. Always verify that the bills match the numbers issued and that the billing document complies with the payer’s requirements.
For the process to be successfully finished, all of the questions in the medical billing audit checklist must be appropriately answered. The medical billing checklist for claims described above is a list of guidelines for enhancing your billing procedures, the efficacy and efficiency of your documentation, and the practice’s financial success.
At Practolytics, we have the necessary equipment and knowledgeable auditors to go deep into the heart of your billing process and identify the risk causes.
Join us today to address the persistent issues with reimbursement and guarantee that you get paid.