A medical billing audit is a systematic review of the billing practices of a healthcare facility to ensure compliance. The audit process typically includes examining all aspects of the billing process, from patient records and coding to claim submission and payment. To accurately complete this, some practices must be followed.

The Art of Medical Billing Audits: 10 Best Practices

Following the best practices involved in medical billing audits is essential to ensure that no mistakes happen during the process. Having a checklist helps, and below are the top 10 practices you should keep in mind:

1. Check patient records

Verifying and authorizing patients’ identities must be included when performing medical billing audits. Ensure you verify details like name, service date, visit date, date of birth, and location on the demographics chart. These details must also be matched with claim documents. Checking if the patient’s insurance coverage was active and valid on the service date is another practice you must pay attention to. Ensure the patient’s information matches the claim data to prevent accidental name switches.

2. Check provider information

Examine the information of both the billing provider and the service provider. It is vital to ensure that the provider mentioned in the documents holds the necessary state licenses and credentials.

Therefore, you must review the documents to verify if they are appropriately signed and authorized by the correct provider when necessary. This practice will ensure that you efficiently complete the medical billing audit process.

3. Check for duplicate records

Also, it is essential to check if a healthcare provider has a record of paid or rejected claims for the same service date and codes. Verify which codes were accepted and which were denied in previous claims. Confirm whether the records submitted in the previous claim match the current ones or if there are additional records.

Additionally, investigate whether the provider has divided service bills for the same date into multiple claims. These aspects require careful examination during the audit.

4. Verify EHR

EHR stands for electronic health records. Another practice you must not ignore is ensuring that IDs are cross-matched across all records. Verify the accuracy of the dates for visits and procedures.

Also, examine the records for clarity and completeness of information. Confirm the proper recording of past medical history, including details on substance abuse, alcoholism, smoking, food and drug interactions, adverse reactions, and allergies.

5. Check the completeness of your medical history

Another practice you must follow is to confirm that the documents maintain the correct chronological order for patient encounters, physician exams, and follow-up visits. Medical billing best practices must emphasize clear and thorough entries, including all patient-listed health issues.

Therefore, ensure that every detail, including referrals to other departments, is present, and check for evidence of continuity and coordination of services between primary care physicians and specialists in the documented records. Additionally, include the date of service, provider information for specialty consultations, and a visit summary.

6. Check diagnostic reports

Document and confirm orders for blood work, radiological tests, and similar reports to ensure their suitability for suspected medical conditions. According to medical billing audit best practices, radiology reports must include image interpretations and proper authorization by the interpreting provider.

Furthermore, ensure that all lab results are comprehensive, include the correct dates, and are authorized by relevant authorities. This will make the whole process of medical billing audits more accurate.

7. Check the completeness of the treatment plan for all diagnoses

The foundation of medical billing audit best practices is the final diagnosis and the patient’s medical condition. This information serves as the basis for the treatment plan.

It is essential to examine whether the treatment plans correlate with the diagnoses and if summary reports from specialty consultants, lab results, and imaging reports are appropriately documented alongside other records. These should correspond with the primary care physician’s findings to ensure accuracy.

8. Document the details of the procedures performed

Examine every record, including the procedure date, type, provider information, and materials used. The medical billing audit process requires comprehensive documentation of informed consent signed by the patient, any witnesses, and the relevant provider.

Generally, you must ensure that the documents include the patient’s complete immunization records and information. Any canceled or missed appointments that were previously scheduled must be documented.

9. Check files on prescribed medication

Another critical practice you must pay attention to during your medical billing audits is ensuring that the documents include all prescribed medication records and refills. If a medical device was part of the treatment, verify the presence of a valid prescription from the ordering physician in the medical records.

Additionally, include medication datasheets appropriately sorted by department and provider. Confirm that there is sufficient documentation regarding patient education and post-procedure follow-up instructions.

10. Verifications of assigned codes

The core element for those curious about medical billing best practices is ensuring coding compliance within billing documents. This involves the verification of various coding details. Always verify the correctness of the CPT and ICD codes and confirm that these codes align with the information in electronic health records.

Verifying the coding process is the most critical aspect of the medical billing audit checklist. Assess the proper use of modifiers in coding and check if the billed units are accurate, matching the appropriate codes for single or multiple units. Also, you should thoroughly review the use of procedural service codes by the medical billing services involved.

Conclusion

Accurate responses to all queries within the best practices of medical billing audits are essential for a successful process. The mentioned best practices in medical billing for claims serve as guidelines to enhance your billing procedures, streamline documentation efficiency, and boost practice profitability.