Medical Billing Audit Checklist: Top 5 Points To Consider

Struggling with increased account receivables, repeated claim denials, or reduced revenue? It means that you immediately need a professional to audit your medical billing services and healthcare revenue cycle management (RCM). 

However, if you want a professional medical billing audit for your practice then there are some significant points that you need to keep in mind. In this article, we have mentioned the top 10 points that should be on your checklist before getting internal or external medical billing audit services. 

But before diving deep into the details of the medical billing audit checklist, let’s understand the concept of medical billing audit and why is it important for your healthcare practice. 

What Is Medical Billing Audit?

Medical billing audit is a well-defined and organized evaluation of compliance and quality of a medical billing system at a healthcare practice. In a medical billing audit, every aspect of running a medical practice is included but the most significant factor that’s observed is “Medical Billing”. 

Therefore, whether you prefer an internal or external medical billing audit, you should ensure that a professional medical billing audit team runs through your medical billing system to ensure compliance with federal and state guidelines and private insurance companies’ requirements. 

Objective Of A Medical Billing Audit

A billing audit aims to ensure that your medical billing and healthcare revenue cycle management system complies with the scrutiny measures of insurance contractors and federal auditors. 

Identify Potential Risks

In a medical billing audit, professionals identify every questionable and problematic area of medical billing procedures. For this purpose, audit professionals use medical claim data and identify the payment behavior of all payers.  Then they generate risk reports to inform healthcare practices about their billing and compliance issues. 

Get Useful Insights Into The Medical Billing System

Otherwise, if your accounts don’t go through a proper billing audit regularly then such errors and mistakes remain unnoticed then it can cause healthcare providers to face a plethora of challenges including federal prosecution, monetary penalties, criminal penalties, exclusion from the insurance networks, claim denials and demands on payback of reimbursements. 

With insightful reports and intuitive medical billing data, healthcare providers can ensure good quality of patient care services at their facilities. Also, they can educate their office staff on documentation and compliance maintenance. 

With these objectives in mind, you can create a successful medical billing audit checklist that can help you screen your entire healthcare revenue cycle management (RCM). It also helps you optimize your medical billing system and monitor payment reimbursements. 

It also empowers your practice by defending you against malpractice litigations, health plan denials and audits from the state and private insurance companies.  

In order to set the scope of medical billing audits, providers should use the appropriate tools and follow a medical billing audit checklist. After performing the medical billing audit, practitioners should prepare reports to analyze the findings of the medical billing audit. It enables healthcare providers and their team to deliver affordable services to patients, collect their reimbursements accurately and avoid risking payment litigations. 

In order to make it easier for healthcare providers to execute a medical billing audit, this article features a complete checklist that can help you make sure that you’ve done your medical billing the right way. 

 

Here are the 10 important points that you should consider for a medical billing audit checklist: 

1. Verification Of Patient Records

The primary step of every healthcare revenue cycle management is to collect patient data. Therefore, medical billing audit professionals should verify the accuracy of patient records. 

Even a slight error in patients’ health information (PHI) can cause problems down the line. While preparing the medical billing audit checklist, include the name, date of birth, date of visit, date of service, place of service, etc, and other patients’ demographic information to verify and cross-match with claim documents. 

It is very important to verify whether the patient’s insurance coverage plan supports the providers’ treatment and diagnostic services. Also, they should make sure that their coverage plan is currently active and verified. It is the responsibility of the healthcare staff to make sure that their patient’s coverage plan is similar to medical records mentioned in the documents i.e. if there is an accidental switch in the coverage plan or patient’s name. 

 

2. Verification Of Provider Information

Along with the patient records, it is also important to verify the details of the healthcare provider who has delivered care services to the patient. For this purpose, medical billing audit professionals should make sure that the providers’ credentials and medical licenses are compliant with the norms of the state. Practitioners should regularly check their documents and make sure that they’re up-to-date and duly licensed to continue their practice without any legislative hurdles. 

A medical billing audit professional should check if the providers’ documents are properly signed and authorized, wherever required, by the right provider. 

 

3. Investigate For Mistakes & Duplicacy In Documents

Medical billing and coding are tightly coupled with documents. If there is duplicate information or mistakes in the documents then it leads to incorrect medical coding & billing practices which eventually results in claim denials/rejections. 

Medical billing audit specialists should track down claim denials and identify errors, mistakes, and other reasons that caused unpaid claims. Therefore, they should also verify if the information of the previous claim submitted and the current one is the same. 

Another mistake that healthcare providers make frequently is “Claim Bundling” (it is the process of submitting a single medical claim for the services delivered to the same patient by the same provider for a single medical condition). For example, if a patient is going through a medical condition & gets the diagnosis, medical treatment, and after care services from the same provider then the provider will submit a single payment bill to the insurance company for the medical treatment, diagnostic and aftercare services. 

However, if the provider has delivered treatment for a medical condition and diagnosis for another to the same patient then the provider should submit separate medical claims which means they’ll not bundle the claims. Otherwise, it’ll make the providers face denials and rejections as well. 

It is the responsibility of the medical billing audit professionals to go through the history of paid and denied claims submitted by the healthcare providers on the same date of service, codes and bills. 

Medical billers should confirm that the provider has distinctively mentioned medical codes for separate procedures. Also, they should check all the dates of services and the medical claims that were filed against all the dates. So they can track down which claim was paid and which were denied. 

 

4. Verification Of Electronic Health Records (EHR)

The most crucial step of medical billing audit is the verification of electronic health records (EHR). Therefore, when it comes to preparing a checklist for medical billing audit then cross-match the IDs in all records. 

Make sure that the healthcare providers have entered the date of services for all visits and procedures. Then medical billing audit professionals should verify the clarity and completeness of the information and that the past medical history of all the patients is recorded appropriately. 

Make sure that the medical records of patients include every piece of information about the patient’s medical history i.e. allergies, adverse reactions, drug and food interactions, smoking, alcoholism, and substance abuse, etc. 

 

5. Check Out The Completeness Of Patient’s Medical History

It is important to make sure that a healthcare practice has complete information about their patient’s visits and their medical history. A medical billing audit professional should make sure that the healthcare facility’s staff has maintained the correct chronology of all documents on patient encounters, physician examinations, and follow-up visits. 

In a medical billing audit, healthcare providers should lay stress on legible and detailed entries on all of the findings by primary care physicians and complete all the health problems enumerated by the patient listed. 

Make sure that the healthcare administrative staff has all the details from referrals to other departments should be there and verify if the documents show continuity and coordination of the services provided by primary physicians and specialty providers. 

Medical billing specialists should also make sure that the date of service and healthcare provider’s information on specialty consults, along with the summary of the visit should also be mentioned in the documents. 

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