A medical billing audit checks if a healthcare practice follows the health care rules and regulations. It looks at everything in the place. The most important part is how they get paid. They check each step to make sure it follows the rules set by the government and insurance companies.
The goal of a medical billing audit is to pass checks from insurance and the government. Doing regular audits is the best way to protect against these checks. Audit is the tool that a medical billing agency uses to find any strange billing and make reports to fix mistakes. If not fixed, mistakes can lead to big problems like fines, losing insurance, or paying back payment.
The audit also makes sure patients get good care and doctors know how to keep records. It checks how money is handled to make sure everyone gets paid right. It helps prevent legal problems and insurance issues.
To do a good medical billing audit, use a checklist. It should cover everything important for your practice. Here’s a general checklist to start with. Let’s look at each item closely:
Checking patient records
When making a list to check medical bills, you need to make sure patient IDs and permissions are correct. Look at details like name, birthday, visit date, service date, and where it happened. Check these against the documents for the bill.
It’s also crucial to see if the patient’s insurance was active on the service date. Make sure the details on the bill match those in the medical records. Sometimes names get mixed up, so be careful.
Check provider information
Make sure the details of the provider who sent the bills and the one who gave the service are correct. It’s important to check if the provider listed in the paperwork is licensed and authorized by the state. Look for proper signatures and authorization where needed.
Find duplicate records
Check if there are any records attached by mistake that are the same as ones already processed. Look into the history of payments and denials from this provider on the same service date. See which codes were paid and which were denied in previous claims. Confirm if the records submitted before are the same as the current ones or if there are extra records. Also, see if the provider split the bills into more than one claim for the same service date. These things need to be checked carefully during the audit.
Checking Electronic Health Records (EHR)
First, compare the IDs in all records. Then, make sure the dates are right for all visits and procedures. Check if the information is clear and complete. See if past medical history is noted correctly. Also, look for details like allergies, reactions to drugs and foods, and habits like smoking or drinking.
Reviewing Medical History and Visits
Check if the order of events is correct in all documents about patient visits, exams by doctors, and follow-up visits. When it comes to billing, make sure everything the primary care doctor finds is written down clearly — including all the patient’s health issues.
Every little thing, like referrals to other departments, needs to be there. Check if the records show that primary doctors and specialists are working together. Make sure the date of the visit, who the provider was, and a summary of what happened are all included.
Checking Diagnostic Reports
We need to make sure that orders for blood tests, X-rays, and other tests are written down and checked to see if they’re right for the sickness we think the patient has. The X-ray reports need to have the picture explained by the doctor and signed off by them, as said in the medical billing checklist. All lab results need to have the right dates and be signed off by the right people.
Making Sure Diagnosis and Treatment Plan Are Complete
The most important part of the medical billing checklist is having all the details about what sickness the patient has and what treatment they need. We have to check if the treatment matches the diagnosis, and if all the reports from other doctors, labs, and scans are included. They should match what the main doctor found to make sure everything is correct.
Lastly,
Keeping Track of Procedures
We need to check every record to see what procedures were done when they were done, who did them, and what materials were used. The checklist also says we need to make sure the patient, anyone watching, and the doctor all agree to the procedure. We need to make sure all the documents are there, including the patient’s immunization records and any missed appointments.
Prescription Documents
All records about medications and refills should be in the documents. If a doctor ordered a medical device for the patient, there must be a complete prescription from that doctor. The documents should also include medication information sheets, sorted by department and the doctor who prescribed them. Make sure there’s enough info about educating the patient and instructions for after the treatment.
Additionally, check out this article about the importance of medical billing software in Revenue Cycle Management (RCM) services.
Checking Codes and Formats
For those unfamiliar with medical billing audit checklists, making sure the billing documents have the correct codes is crucial. There are many details to look at when it comes to coding. Always make sure the correct CPT/ICD codes are on the bill. Check if the codes on the bill match what’s in the electronic health records and if the diagnostic codes are very specific based on the medical records.
Checking the coding process is the most important part of the medical billing audit checklist. You should also see if modifiers are used correctly in the coding and if the number of units billed is right. Check that the right procedural and ancillary service codes are used. Also, look for potential problems like using unlisted codes, coding incorrectly, or charging too much.
Final Word
All the questions in the medical billing audit checklist need to be answered correctly to finish the process. The medical billing checklist above is a set of tips to make your billing better, make documentation more efficient, and increase profits at the practice.
