30 Aug Avoid Legal Hassles with a Checklist for Your Medical Billing Audit
Why do you need a checklist for your medical billing audit? Because it’s vital for the future of your practice.
Here’s why: it’s better if you spot any problems in your medical billing process through your own audit first, rather than have them exposed by an audit performed by the government or an insurance company that suspects irregularities.
Exactly what is a medical billing audit? It’s an organized analysis of how well a healthcare facility is legally compliant and how well it meets quality standards. The audit process includes every aspect of running a practice, but the most significant part is investigating the process leading to reimbursement. You must examine every step leading to billing a claim, guaranteeing it’s compliant with federal and state guidelines and private insurance company regulations.
When you’re performing a medical billing audit, it must be able to stand up to an examination by federal auditors and insurance contractors. By scheduling audits at your healthcare facility, you’re safeguarding against federal and insurance company audits. As a result of auditing the claim data and creating risk reports, you can identify any questionable billing patterns so your healthcare facility can identify its compliance oversights. If physicians can identify these errors in advance, they can avoid such serious consequences as possible federal prosecution, monetary penalties, criminal penalties, and demands to pay back reimbursements, in addition to being barred from insurance networks.
Medical billing audits are designed to ensure high quality patient care. A huge benefit for you is that it enables you to analyze your revenue cycle management and optimize it. The audit also protects you from malpractice litigations, health plan denials, and audits from state and private insurance companies.
Did you verify the assigned codes and formats used?
The most important part of your medical billing audit checklist is this: verify the coding process. You’ve got to be compliant with coding rules.
Were the right CPT/ICD codes used in the claim? Did the codes assigned in the claim align with electronic health reports and the applied diagnostic codes? Were the right coding modifiers used? Did you list the correct number of units billed? Did you use the right codes for a single unit or multiple units? Check that you used the right procedural codes and ancillary service codes. Investigate to see if possible risk factors such unlisted codes, miscoding, unbundling of services, and upcoding occurred. Make it a habit to cross check bills with assigned codes: does the billing document meet the payer’s standards?
Did you verify patient records?
Meticulously verify all patient information, including identity data and authorizations. Did you get the patient’s name, date of birth, date of visit, date of service, and place of service right? Verify and crossmatch every detail in your claim documents.
When services were rendered, was the patient’s insurance coverage plan active and valid? Do the specified claim demographics and data match what’s recorded in patient medical records? Double check, because it’s easy to commit oversights.
Did you verify provider information?
Verify the details of the provider that issued the bills and the provider who performed the service. The provider listed in the documentation must be duly licensed and credentialed according to state regulations. Was the document properly signed and authorized by the correct provider?
Were any duplicate records attached by mistake?
During your audit, confirm: Did this healthcare provider pay or deny claims on the same date of service? In the previous claims, which codes were paid, and which were denied? Are the records submitted in the previous claim the same as the current one? Or did you include additional records? Learn whether the provider split the bills of service for the same date of service into more than one claim. It’s crucial to thoroughly analyze all these details in your audit.
Did you verify electronic health records (EHR)?
Double-check the ID information in all records to make sure it’s clear and complete. Did you enter the correct dates for all visits and procedures? Is past medical history recorded properly? Is there any data on allergies, adverse reactions, drug and food interactions, smoking, alcoholism, and substance abuse?
Is the patient’s medical history and record of physical visits complete?
Verify the correct timeline in all the documents regarding patient encounters, physician examination, and follow-up visits. The primary care physician must have recorded legible and detailed entries on all the findings, with a complete account of all health problems encountered by the patient.
Documentation should include every detail from referrals to other departments. Do the documented records show the continuity and coordination of services provided by primary physicians and specialist providers? Be sure to include the date of service and provider information on specialty consultations, with a summary of the visit.
Did you verify diagnostic reports?
You must document and verify procedures like orders for blood works and radiological examinations if they’re appropriate for the suspected disease conditions. Be certain radiological reports are completed, accompanied by the interpretation of the image and the authorization by the provider who interpreted the result. Are all lab results complete, with appropriate dates and authorizations by providers?
Are the diagnosis and treatment plan complete?
It’s imperative to get the details of final diagnosis and disease condition right, since they’re the foundation of the treatment plan. Was the treatment plan consistent with the diagnosis? Were the summary reports from the specialist consultants, lab reports, imaging, and scan reports recorded along with the other documents? They should align with the primary care physician’s findings.
Did you include details of the procedures performed?
Ascertain that every record gives the correct information regarding the date and type of procedures conducted, information on the provider, material list, and quantities used for the procedure. Include the informed consent authorized by the patient. Do the documents include the patient’s complete immunization records, plus details on all missed or cancelled appointments previously scheduled?
Do the documents mention prescribed medications?
Be certain to include all records on drug prescriptions and refills. If a medical device was prescribed for the patient as part of the treatment, verify the ordering physician’s
valid prescription. Include medication datasheets, organized according to the department and provider issuing the prescription. Is there enough documentation on patient education and follow-up instructions provided post-procedure?
How Medusind Can Help
If preparing a medical billing audit seems like a lot of work, it is. And isn’t your staff overworked enough? They’re not experts at medical billing audits—but we are, with over 20 years of experience. That’s why Medusind is a national leader in medical billing. As experts in medical revenue cycle management, we know what to look for during a medical billing audit. Contact us and see how we can devise a cost-effective solution that will block your practice from unforeseen consequences while ensuring you receive the reimbursement you deserve.
