Medical Billing Audit & Compliance

Code Billium (CB) offers a full range of health information management and billing services to hospitals and physician providers, including comprehensive medical billing audits.

What is a Medical Billing Audit?

A medical billing audit is a thorough examination of clinical documentation and the overall medical billing process for a healthcare provider. The goal is to ensure that the billing and coding practices are effective, accurate, and in line with regulations.

During the audit, a CB auditor will review various records, including:

• Medical records
• X-rays and lab reports
• Financial records (charges entered, Explanation of Benefits (EOBs), and accounts receivable)
• Policy-related documentation required by providers or the government

The purpose is to meticulously analyze the healthcare provider’s medical records and billing data to identify and correct any inappropriate billing practices.

Audits can be conducted in two ways:

1. Prospective audits: These take place before claims are submitted to payers.
2. Retrospective audits: These occur after claims have been submitted.

Some practices conduct prospective audits for new providers and retrospective audits for existing providers.

Types of Medical Billing Audits Provided by Code Billium (CB)

• Inpatient Auditing & Compliance
• Outpatient Auditing & Compliance
• Physician Auditing & Compliance
• Pharmacy Coding & Billing Reviews
• Specialty Areas

Goals of a Medical Billing Audit

• Identifying and Correcting Billing Errors: Detect and fix errors in the medical billing process.
• Maximizing Revenue: Ensure proper reimbursement for services rendered.
• Improving Compliance: Avoid costly penalties by meeting regulatory requirements.
• Gaining Insights and Analytics: Assess billing performance and identify trends.
• Increasing Transparency: Improve clarity and communication throughout the billing process.

Scope of a Medical Billing Audit

A medical billing audit from CB covers all aspects of the billing cycle, including:

• Insurance verification
• ICD-10-CM and CPT coding
• Claim submission
• Payment posting and follow-up
• Denial management

Advantages of Medical Billing Audits by Code Billium (CB)

• Coding Compliance: Identify and correct potential inaccuracies before they are flagged by payors or regulatory authorities. Build staff confidence and ensure up-to-date coding practices.

• Compliance Assurance: Protect practices against fraudulent billing activities. Address reimbursement deficiencies and ensure proper coding to boost revenue.

• Administrative Benefits: Establish standards for claims submission, promote a positive work environment, and reduce the likelihood of external audits.

• Increased Profitability: Identify under- or over-billing and unrecorded charges, leading to more accurate and profitable billing practices.

• Proactive Problem Solving: Prevent issues before they are flagged by authorities, improving medical record documentation and increasing payments for services provided.

Why Regular Medical Billing Audits are Essential

• Effectiveness and Efficiency: Regular audits help healthcare practices assess their claims management processes and enhance efficiency.

• Protect Against Fraud and Errors: Medical billing audits are vital for avoiding substantial fines or penalties associated with Medicare reporting errors, especially with the ongoing transition to ICD-10 coding.

• A Culture of Compliance: Audits establish standards that promote a culture of compliance, reduce stress for staff, and help retain top talent.

Conclusion

A medical billing audit is a valuable tool for healthcare providers to ensure accuracy, compliance, and profitability. Code Billium (CB) helps practices protect their revenue cycle, avoid errors, and ensure smooth claims management. If you’re interested in learning more about the medical billing audit process, contact CB today!