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Medical Billing Audit: A comprehensive Solution for Practices!
Medical billing audit plays a vital role in the fin angel health of medical practices. It helps them to stay strong and compliant in the medical industry. The main purpose of medical building audits is reviewing the billing services of practices and minimizing the errors in claims.
In this way, they can run the building services smoothly, and focus on providing high quality medical services. This article will explore the medical billing audit in detail.
What is a Medical Billing Audit?
Spokennoise medical billing or dead is a comprehensive process to check how efficient and trustworthy, the documents of a practice are. In this process, the health record of a medical practice is examined in detail. It reviews all the medical billing information given to the insurance payers.
Monitoring and making corrections in inappropriate billing processes is the main purpose of medical billing audits. It is important to find out the compliance issues as the medical billing directly effects the financial health of a practice.
Types of Medical Building Audits!
The medical billing audit can be conducted in several ways. Some major types of medical billing audits are mentioned below:
Internal Audit
Turn on building orders are conducted to make sure that the payments and claims process is running properly according to the legal rules. It serves as a strong defense against the charges of crimes to the medical practices.
External Audit
Is an external audit. The outsiders, who are professionals and experts in the medical billing audits, conduct it. They are highly skilled and fully informed of audit's knowledge. They give an accurate evaluation of the billing procedures in a medical practice.
The external audit is beneficial because it diminishes the conflicts of interest. As such conflicts can harm the doctor or any other internal employee. It also enables the practice to do things collectively.
Government Healthcare Audit
Government health care audits mainly maintain the Accounting ability and insurers the compliance in medical billing. In this audit the government's medical billing audit agency fulfills all the billing audit formalities. The main objective is to check that the healthcare providers are following all the regulations, having accurate billing services, and is not involved in any fraudulent activity. Medicare and Medicaid are the two prominent audit agencies that conduct government audit.
Medicare
Medicare audits review the medical records and billing data. Its main purpose is to make sure that the claims submitted to get payments are legal, have precise medical coding, and proper supporting documents are in place.
Medicare used to conduct many types of audits, such as:
Sample Audits.
CERT (comprehensive error rate testing).
RAC (recovery audit contractor).
Medicaid
Medicaid is a medical auditor that investigates the records, ensuring that Medicaid is billed precisely against the provided services, and they are recorded in proper documents.
The main part of audit procedures is MIP (Medicaid Integrity Program). It's goal mainly lies in preventing, identifying, and recovering the Medicaid payments.
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Medical Billing Audit Process!
Making careful plans and execution is required to conduct an authentic medical billing audit. Six main steps are involved
in the whole process; those are mentioned below:
Check the Audit Scope!
Random Audit.
Thorough Audit.
Hybrid audit. In random audits, large and minor audits are chosen in accordance with their dollar value. In effective audits, thorough examination of claims is involved, and emphasizes the reimbursements.
In the hybrid audit, all the samples of claim types are examined. It deeply looks into the gaps. It uses the methodology combination of two audits, i.e, a random and thorough audit. The medical practice should decide the scope of the audit according to their internal and external resources and support. Also keep the number of claims in mind for examination, while choosing the medical billing audit.
Determine Sample Size!
Normally, ten to fifteen charts as an audit sample size are enough. It is advised by the OIG to use five to ten charts for each medical provider using RAT STATS for statistical sampling, when many physicians are involved in a medical billing audit.
The tools like RAT-STATS make the medical practices capable of understanding the sampling techniques applied by the payers. As a result, the practices can collect thorough information pinpointing the risk areas and active in compliance processes. In this way, the payers audit will not get hidden liabilities if the practices themselves identify such areas and manage the paperwork and medical coding.
Collect Documentation!
In addition, you should be familiar with the chart's layout and the other unique forms, like the history form, problem list, and prescription sheet.
Conducting the Audit!
Old and new patients.
Consultation and transfer of care.
Time-specific code requirements.
Emergency medical services.
Non-physician medical services.
Analysis of Medical Audit Findings
Incomplete and/or incorrect modifier usage.
The diagnosis codes that are not correct, involving ICD-10 codes, do not cover a specialty or support a medical need.
Wrong diagnosis association.
Services rendered, but billing is pending.
Create the Audit Report!
Regulate the quantity of both the contacts that were recorded correctly and incorrectly. Notice the trends against codes and observe the mistakes. Highlight the errors or risk area to form the categories like obvious CPT codes, payers, providers, or specialties. Clarify all the errors by giving reference to the relevant standards.
At the end, propose the measures that should be taken for corrections. In addition, suggest training or changes for the process of documentation. Emphasize follow-up analysis for determining whether the proposed strategy was effective or not.
Medical Billing Audit Checklist for Practices:
The stages involved in the medical billing checklist for practices are the following:
Stage 1: | Stage 2: | Stage 3: | Stage 4: |
1- Setting up the size and staff requirements for the medical billing audit. 2- Choose a team member for conducting the evaluation or hire a third-party expert. 3. Make complete plans to build strategies for your medical billing audit. Including the selection of a specific number of charts against individual payers and providers and comparing the documents for completion. 4. Print and issue a formal audit plan. | 1. Look at your billing reports to identify the threatening patterns and risk areas. Compare the current and previous reports to find errors. 2. Choose a specific period for the evaluation of frequency between your and your rivals medical billing services. You can do this by carrying out the E and M frequency reports. 3- Issue a report to define the reimbursement procedures against your CPT codes. | 1- Make the aim to get advanced after collecting all the above-mentioned information. 2- Make efforts to convince the payers to pay the rates on which they were agreed. Try to get paid precisely and instantly. 3- Make strategies to get payments from late payers and follow up again and again. 4- If you find an internal issue, don’t overlook it. It may demand additional training for your employees and service suppliers. | 1. Make a routine to conduct a medical billing audit at your medical practice. 2- Facilitate the medical billing audit process by making strategies, like running reports on a regular basis and keeping track of overall collections. |
Medical Billing Audit Checklist for Practices:
The stages involved in the medical billing checklist for practices are the following:
Stage 1:
1- Setting up the size and staff requirements for the medical billing audit. 2- Choose a team member for conducting the evaluation or hire a third-party expert. 3. Make complete plans to build strategies for your medical billing audit. Including the selection of a specific number of charts against individual payers and providers and comparing the documents for completion. 4. Print and issue a formal audit plan.
Stage 2:
1. Look at your billing reports to identify the threatening patterns and risk areas. Compare the current and previous reports to find errors. 2. Choose a specific period for the evaluation of frequency between your and your rivals medical billing services. You can do this by carrying out the E and M frequency reports. 3- Issue a report to define the reimbursement procedures against your CPT codes.
Stage 3:
1- Make the aim to get advanced after collecting all the above-mentioned information. 2- Make efforts to convince the payers to pay the rates on which they were agreed. Try to get paid precisely and instantly. 3- Make strategies to get payments from late payers and follow up again and again. 4- If you find an internal issue, don’t overlook it. It may demand additional training for your employees and service suppliers.
Stage 4:
1. Make a routine to conduct a medical billing audit at your medical practice. 2- Facilitate the medical billing audit process by making strategies, like running reports on a regular basis and keeping track of overall collections.
Federal Regulation and Compliance In Healthcare Audit:
As employed by the AAPC, Medicare Trust Funds- The Hospital Insurance Trust Fund and the supplementary Medical Insurance Trust Fund should be safeguarded by the CMS (Centers for Medicare and Medicaid Services), which is the largest health care provider of the USA.
Mentioned in U.S Government Accountability Office report, incorrect medical claims are submitted by the healthcare organizations every year. It results in inaccurate payments.
In collaboration of CMS with Part A and Part B Medicare Administrative and Durable Medical Equipment MACs (DMA MACs) for preventing inaccurate payments to endanger the Medicare Trust fund. CMS also work in collaboration with many other contractors who protect taxpayers and the Medicare Beneficiaries. There are different CMS beneficiaries, such as:
(RAC) Recovery Audit Contractors:
Recovery Audit Contractor investigates post-payment claims. It helps in recovering the erroneous payments given to healthcare providers under Medicare FFS (fee for service plan). Other than that, RAC finds out errors to make CMS take actions, whether directly or through MACs. Consequently, further inaccurate payments will be stopped.
SMRC- Supplemental Medical Review Contractor:
The Supplemental Medical Review contractor is Nordian Healthcare Solutions in the USA. The SMRC evaluates health of Medicare Part A, Part B, and DME claims to minimize the amount of inaccurate payments. Nordian is an organization and its role is to identify fraud, abuse, and inappropriate care in the field of medical. The review against fraud or inaccurate payments by SMRC, results in the process of recovering payment. This is how it is an integral part of medical billing audit.
PPI MEDIC ( Plan Program Integrity Medicare Drug Integrity Contractor):
The Medicare Drug Integrity handles the Plan Program, Part C and Part D. It analyzes factors like data analysis, audits, risk assessment reports, plan provider education, and outreach.
I- MEDIC ( Investogations Medicare Drug Integrity Contractor):
The Medicate Drug Integrity monitors the queries about Medicare Advantage (Part C), and prescription drug coverage (Part D). It regulates the fraud, waste, and abuse. The practitioners, prescribers, and pharmacies are allowed only for little Part D advantages.
UPICs- Unified Program Integrity Contractors:
Unified Program Integrity Contractors perform the functions of regional operations for identifying and preventing fraud, waste , and abuse of medical claims. These claims are submitted under Medicare Part A and Part B, Medicaid, and the Medicare-Medicaid data match program.
In Medicare UPICs target three domains DME, home health, and hospice.
UPIC has replaced the ZPIC ( Zone Program Integrity Contractor), PSC (Program Safeguard Protector), and MIC (Medicaid Integrity Contractor). These contractors are active in five regions of the country.
How Medical Billing Audit Helps Your Practice:
With the help of comprehensive medical billing audit the practices can get optimized billing process. The benefits of medical
billing audit are mentioned below:
1. Safety from Billing Errors ⤦
Due to billing errors medical practices can become at risk. In addition, their services become questionable in federal and state legal investigations. As a result the practices may be proven unreliable. Erroneous claims can result in irreparable losses. The fraudulent claim filing and financial penalties due to incorrect claims result in huge losses. The medical billing audit on regular basis detects false charges to avoid future consequences.
2. Helpful for Coding Staff ⤦
Medical billing audits help in finding out the coding errors, in getting solution of the issues, and to make sure that the latest coding procedures are being used. Audits are necessary to align the billing processes and make them according to the set standards. The billing processes must comply with the rules of HIPPA.
The health care facility and it’s billing partner may face severe issues, such as legal penalties resulting in low reputation and may be a heavy fine. Therefore, audits are necessary to avoid the losses due to non-compliance.
3. Establish Administrative Standards ⤦
The medical billing audits help ensure the administrative team that the right, precise, and on-time claims are submitted. The audits create friendly environments for employees and avoid stress and tension. The positive and stable work environment attracts more expert and professional employees. The inaccurate billing for services and other processes is caused by under- or over-coding, overusage of codes, and improper unbundling practices.
4. Improved Patient Care ⤦
The medical billing audits comparatively increases the patient care. The medical practice can focus on the best services for the provision to the patients. The regular audits can help tracking and monitoring the best services of practice can provide to the patients. It also encourages the doctors to give best care to their patients. As a result, when the patients get better experience, the revenue cycle of a healthcare practice improves.
5. Increased Profits ⤦
The medical billing audits help in avoiding frauds against billing and claims. Due to a proper check and balance, the health care organizations become able to access themselves that whether they can comply with the ICD-10-CM. The audits make sure to use the electronic data efficiently, to get the required things from patients records. Consequently, the possibility of claim denials is reduced, resulting in improved profits.
MedHub, The Best Provider of Medical Billing Audit Services in the USA:
The practices may face a lot of problems when it comes to revenue. MedHub resolves all those problems by presenting comprehensive medical billing audit services. We solve your issues by making strategies like addressing the major hazards, enhanced accuracy, improved profits, and providing complete comfort to you.
We have been serving for years by ensuring successful solutions to the practices, in accordance with the compliance. We not only deal in medical billing audits but also provide other services like:
Medical Billing.
A/R management.
Claims management.
Medical Coding.
Credentialing and Enrollment.
1. We find out and make corrections in your medical billing.
2: Maximizing the revenue by ensuring timely reimbursement.
3: Keep compliant to avoid the cost penalties.
4: Deep analysis of the billing performance.
5: Make your billing processes clear and improved.
1- We analyze the billing records.
2- Making audit strategies that are convenient for the employees.
3- Using the PMS.
4- Issuing complete audit reports.
5- Giving trainings to your staff.
What Will Your Practice Get?
1- Precise medical billing.
2- Alligned reimbursement.
3- More clarity.
4- High number of patients.
5- High revenue.
Want to boost your revenue? Let's talk!
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Clean claims on the first submission
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HIPAA Compliance
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Live Support
30%
Increase in Collections
Final Thoughts
The medical billing audits can provide advantages to the medical practices. They can protect the health care organization from financial loss, legal penalties, and damage to reputation.
Other than that, the audits can result in high profitability and enhanced patient care. Practices should not avoid this process,and must perform medical billing audits on a regular basis.
MedHub is aimed at providing the best medical billing audit services to providers in the USA. You can contact us to avail our services. Contact us now and get the best medical billing audit services in the USA.
FAQs
Medical billing is the process of ensuring that healthcare providers are paid for their services
and that patients are paid accurately.
There are two main types of medical billing: institutional and professional.
Medical billing helps to ensure that healthcare professionals are paid on time and that patients receive accurate statements. It also helps to reduce the risk of missing, overcoding, or undercoding claims.
Medical billers should stay up to date with medical billing regulations and best practices.
Medical billers should know how to handle rejected claims from insurance companies.
Medical billers should be able to help patients understand their claims and bills.