In today’s healthcare world, billing integrity audits protect the practice from potential risks and enhance its overall efficiency.
These audits identify errors, such as incorrect coding, duplicate charges, or unbilled services, which can lead to revenue loss or overbilling.
Accurate billing ensures the practice collects the full reimbursement it is entitled to, improving cash flow and financial health.
In addition, these audits help practices comply with payer contracts, Medicare, Medicaid, and other regulatory requirements, reducing the risk of fraud investigations or penalties.
It can also catch unbilled services or under-coded claims that result in lost revenue or avoid costly recoups due to overpayments resulting from errors or over-coding.
This review looks closely at a healthcare provider’s billing procedures. It ensures they follow the relevant rules, guidelines, and industry standards.
Our blog will guide you through the steps of a billing integrity audit. It will also show how Legacy Consulting Services offers expertise in this field.
Steps in a Billing Integrity Audit
Here’s an outline of the critical steps involved in a billing integrity audit:
1. Pre-Audit Planning
The first step in any successful audit is setting clear objectives. Decide what the audit will cover. Will it look at the entire revenue cycle or focus on specific problem areas? At this stage, you’ll determine which providers, departments, or services are the primary focus. Planning helps gather all necessary data and keeps the process streamlined.
2. Data Collection and Review
Once the scope is established, the next step is gathering the relevant data. This includes financial records, claims, clinical documentation, and coding records and data analytics.
An in-depth review of these documents helps auditors understand how charges are captured, coded, and submitted. Data collection also helps to establish a baseline, which is critical for identifying any errors.
3. Cross-Checking Codes and Compliance Verification
This step involves reviewing documentation and checking procedure codes (CPT), diagnosis codes (ICD-10), and modifiers.
Verifying that coding, billing and documentation match is an important part of this process.
Every billing code and modifier must meet specific requirements for each payer.
This step helps identify under-coding, over-coding, or any incorrect billing levels.
4. Identification of Deficiencies and Recommendations
During the review process, auditors note any errors or areas where compliance may be lacking.
This step allows the audit team to identify underpayments, overpayments, and any discrepancies in billing codes or fee schedules. Once the team identifies gaps, they provide recommendations on corrective actions.
5. Corrective Action Plan
The next step is to establish a corrective action plan.
This plan should address the deficiencies identified during the audit and provide clear steps for improvement. It can range from adjusting coding practices to implementing new training for billing staff.
Ensuring that these changes are actionable and easy to follow is key to maintaining compliance and accuracy moving forward.
6. Education
The last step is to prepare educational materials to re-train billing, administrative, and clinical staff on the findings and review the corrective action plan to ensure these errors do not continue.
A follow-up audit is recommended depending on the severity of the errors within the next 90-120 days.
How Legacy Consulting Services Conducts Billing Integrity Audits
Legacy Consulting Services offers expert billing integrity audits. Our comprehensive approach includes reviewing clinical documentation, billing, and coding to ensure accurate and compliant submissions for maximum reimbursement. We also focus on specific areas that matter to you. This provides a customized approach for each practice.
Here’s what you can expect when working with Legacy Consulting Services:
- Thorough Chart Audits: Our team can review a sample of charts for each of the top payers and providers. We review documentation, coding, billing levels and reimbursement to ensure that all aspects are correct for each claim.
- Actionable Results: After finding any issues, we create a clear action plan. This plan helps you meet compliance and achieve accurate reimbursement. This includes assistance with any needed implementation through our Medical Billing Services.
- Payment Accuracy Reviews: Our audits go beyond basic compliance. We check for underpayments, overpayments, and fee schedule errors through claims and EOB reviews.
- Extra Training and Support: Based on your practice’s needs, we can offer training and ongoing assistance as well as quarterly reporting or billing audit reviews. This will ensure compliance as your practice grows.
Final Thoughts
Conducting regular billing integrity audits is essential for healthcare providers desiring to maintain accurate, compliant billing processes.
By understanding each stage of the auditing process, your organization can improve its financial and regulatory foundation. Working with a reliable partner like Legacy Consulting Services can reduce concerns about billing and compliance. This includes issues related to Medicare, BCBS, and other payers.
Whether your practice needs a full audit or specific help, Legacy Consulting Services is here for you. With the right support, your organization can trust its billing process. This lets you focus more on providing great patient care.Contact us today to discuss how we can assist.