Supporting service
Medical billing audit services
A medical billing audit is a review of claims against the medical record and the payer’s rules, to find coding and billing errors before a payer does and fix what caused them.
Is your billing audit-ready?
0 of 5Five questions about your own practice. Nothing is sent anywhere.
Are codes and visit levels checked against the notes regularly?
Are modifiers 25 and 59 used only where payers expect them?
Has your billing been checked against this year’s payer and CMS rules?
Could you report and return an overpayment within 60 days?
When errors are found, does someone change the process and check again?
Answer as many as you can; the areas to look at first appear here.
Internal or external audit? One finds the problems first.
Any practice can be audited by a payer or by Medicare’s contractors. An internal audit looks at the same things first, on your terms.
Internal audit
A review your practice chooses to run, of a sample of claims against the documentation, so errors are corrected and their causes fixed.
External audit
A review by a payer or a government contractor, such as Medicare’s Recovery Audit Contractors, which can ask for records and take back payments the records don’t support.
Why audit your billing?
Coding that drifts from the notes
Over time, codes and visit levels can drift away from what the documentation supports, and nobody notices until a payer asks for records.
Modifiers used out of habit
Modifiers such as 25 and 59 added routinely, where payers expect them only in specific situations.
Rules that change
Payer policies, CMS rules and code sets change through the year, and a process that was right last year may not be now.
Overpayments you have to return
An identified Medicare or Medicaid overpayment has to be reported and returned within 60 days.
Findings with no follow-through
An audit that lists errors but doesn’t change the process that made them finds the same errors next time.
How a medical billing audit works
Choose the sample
We agree with you which providers, services and payers to review, and draw a sample of claims from them.
Review the documentation against the billing
Each claim in the sample is checked against the medical record: the codes, the visit level, the modifiers and the diagnoses.
Check it against payer and CMS rules
Claims are checked against payer policies and CMS rules, not just against the code book.
Report what was found
You get the findings in plain words: what was wrong, what it means and what to correct, including any overpayment to return.
Fix the cause and train your team
Corrections go into the billing process, and your team is shown what changed and why.
Check again
Areas with findings are reviewed again later, so a fix that didn’t hold is caught.
Related billing services
Related specialties
Further reading
Billing audit questions
What does a medical billing audit check?
How often should a practice audit its billing?
Find out what an audit of your billing would find.
Unsure how much revenue you are missing? Start with a complimentary billing audit.
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