How To Perform Medical Claim Audit

Although your medical practice has credentialed experts in managing the entire revenue cycle process and billing, regular analysis and examination by third-party auditors are crucial to ensure security and efficiency through checking multiple steps, including practice compliance, coding, and documentation accuracy, and highlighting errors that potentially may lead to practice liability. However, hiring an external medical claim auditor or conducting the process internally requires a good understanding of the process, as only an appropriately performed claim audit will increase billing efficiency and improve the Practice's success. Let’s dig deep into the details of how medical claim audit boosts your practice efficiency and the necessary steps involved in the process.

Why Should Your Practice Conduct a Medical Claim Audit?

The ever-changing field of the healthcare industry requires providers and practitioners to stay informed of the several updates and novel trends in coding and billing to ensure the Practice's efficiency. Furthermore, this is the more efficient way of performing measures to protect your healthcare plan’s assets and responsibility to the participants as a sponsor. Considering the significance of conducting an internal medical claim audit, providers in Practice can ensure data integrity, promote patient data security and quality, and enhance revenue performance. As per the previous data, 26% of the healthcare community conducts internal audits monthly, 34% quarterly, and 32% rate leads annually in their office. Moreover, periodic internal medical coding audits are one of the significant components of OIG’s seven essential components of a voluntary compliance program for physician practice.
From monitoring the physicians’ implementation of coding and documentation and the increasing accuracy rates while applying technology in the process, auditing claims ensure the Practice’s safety and productivity while enhancing revenue. Some of the reasons why your Practice needs regular medical claim audits are:

Ensure insurance payers pay claims correctly

Conducting regular audits in medical coding ensures claims are being paid in full. Plus, you will prevent your practice from complaining to BBB or healthcare regulatory bodies about correctly paid claims or negative customer reviews.

Audits Ensure Compliance With Regulations

Healthcare regulations keep updating, and the providers’ most significant challenge in practice is maintaining these rules because the insurance providers base reimbursement on practice compliance. In contrast, a non-compliant practice has considerable repercussions that your Practice might face. Regular coding and claims audits ensure the codes are applied appropriately, following the compliance principles and helping the practice flourish amidst complex challenges.

The Advanced Technological Span And Question Of Accuracy

An unpredictable advancement in technology in healthcare practices also advances the need to ensure the accuracy of reporting and claim processing. Claim auditing helps practitioners adjust to this challenge and allows providers to anticipate practice costs and manage those according to the best of their business.

Your Practice Ensures the Right Partners

The intricate web of medical coding and claims management only needs experts and credentialed professionals to handle the Practice effectively. Moreover, your plan must benefit the most qualified and eligible partners performing your Practice. Audits help you ensure only suitable candidates receive benefits while finding anyone inappropriately entertaining the benefits will return money to your training to hiring more qualified partners in the Practice.

Use Third-Party Medical Claim Audits

Considering the varying benefits of conducting an internal or external audit, your practice may easily opt between both per the needs. However, third-party claim auditors bring unique benefits in terms of objective results that you may not acquire while working with internal members. Their impartial approach and loyalty to your office help you considerably with what works best for your practice sustenance and revenue.
MedsIT Nexus is one of the leading service providers in the industry, ensuring medical coding, billing, and claims auditing efficiency. Their effective strategies and expertise increase your Practice money because they cost you from the amount they save your company from various areas of medical claims management.

Use Medical Claim Audit Checklist To Ensure Your Practice’s Right Track

Claim auditing in healthcare practice is one of the significant steps in preventing denials and other healthcare financial pitfalls like catering to complicated payer requirements and staff shortages, as they offer you identification of gaps to fill in your Practice. Deciding on third-party claim auditors may reduce your efforts to monitor practitioners’ specific qualifications and expertise to handle several tasks. However, conducting an internal claim audit leads you to learn efficiently the several steps and tips to save your Practice from financial drain. Here is an informative auditing checklist highlighting a step-by-step auditing process to get help:

Pinpoint Your Medical Claim Audit Purpose

• In case your Practice performs an audit for the first time, start with the baseline.
• A random internal retrospective audit is a good initiative to detect vulnerabilities and post-payer processing.
• Examine claims before payers proceed with claims for progress to prospective audits.
• Target certain areas, including time-based billing, level four of five E/M services, HCC capture rates, and quality measures for value-based contracts.
• Address significant errors mentioned in the OIG work plan.
• Focus on accounts that were previously flagged for deficiencies while external claim auditing.
• Strategically narrow the scope of internal audits to optimize time and prioritize strategic objectives that can lead to higher ROI.

Establish A Sample Size Of Your Claim Audit

After you decide on the focus of your claim audit, it's time to establish a sample of claims your Practice will audit as per the number of providers in your office. However, experts suggest that you may acquire ten to twenty claims per provider, while extended practices like hospitals usually take 25 to 30 claims per provider. Ensure that the more the increased claim size, the more chances of accurately determining trends and outliers.

Ensuring Accuracy While Reviewing Claims

Once you have collected the sample of claims for auditing, practitioners need to review each claim thoroughly to ensure accuracy. However, the more the extended number of claims, the more time-consuming the procedure becomes for practitioners. The claim review will determine several essentials, such as clinical documentation compliance with payer requirements, coding accuracy by following official coding guidelines, coding and documentation meeting the criteria of internal policies, and the causes of errors in the process.

Declare Audit Results

• Reviewing Claims will reveal a big picture of gaps in your Practice that you must share with the participants, including:
• Educate physicians and personnel to identify areas that need improvement.
• Consider providing education and training on medical coding assignments accurately if needed.
• Your Practice can update claim processing methods and coding procedures on audit insight.
• Create a comprehensive final report with improvement recommendations.
• Quantify the financial impact, such as revenue lost or saved due to coding practices.
• Develop a corrective action plan for issues that were identified.

Create An Action Plan To address audit Issues

Once your Practice has identified potential issues and weaknesses, create a customized plan based on the audit results. For example, if outdated codes are a common issue as specified, you must schedule training and in-service on coding and guideline changes. Moreover, ensure the plan resonates with the nature of deficiencies identified in the audit.

Make A Follow-Up Medical Claim Audit For Revenue Integrity

• A follow-up audit will ensure everyone involved in the Practice receives education and opportunity to practice.
• The role of external medical claim auditors must be addressed, and unbiased auditing processes.
• Partnering with a third-party auditor will offer your Practice an independent evaluation.
• They will provide a different perspective and extensive expertise in a smooth budget.
• External audits will prevent your Practice from any interruption in the process.

Trending Reports In Medical Claim Auditing

Considering the coding compliance audit, trending reports have significant benefits in terms of anticipating coding quality strengths and weaknesses. It helps claim and coding auditors in various ways:

• Aid in measuring performance patterns, beneficial or harmful.
• Mari E. Cely emphasizes the value of gaining insights from historical data.
• Trending analysis ensures accuracy and competitiveness in health information management (HIM).
• Helps improve coding staff’s potential for replication and propose areas of improvement.
• Predict long-term performance and help in decision-making for practical implications in administration.

While diagnosing the ICD-10-CM accuracy rates in trending, a group of consultants helped clients measure the coders’ lack of applying accurate HCC diagnosis codes. Moreover, they also re-educated these coders on the importance of assigning these codes appropriately.
As the results found, for a 4Q audit, the ICD-10-CM diagnosis and ICD-10-PCS procedure accuracy rates dropped entirely. With the help of trending reports, they examined that the coders were miscoding many procedures and diagnoses as new 10/1 codes.
These experts offered additional information and education on the 10/1 updates, and their accuracy rates increased for the audit. Moreover, a comparison trending report for the next 4Q was made to ensure the coder's understanding and knowledge of additional 10/1 code updates.

MedsIT Nexus Understands The Goals Of Your Medical Claim Auditing

Eliminating denials amidst the intricate world of medical coding and billing isn’t without challenges that can be overcome with a group of experts by internally monitoring the process. A leading coding audit services provider such as MedsIT Nexus Medical Billing and Coding will heed to streamline various auditing tasks. We will help your claim processing while undertaking multiple steps and strategies, specifically in, what an effective provider’s documentation should look like. Our extensive expertise and knowledge will provide your team with supportive training and education on performing a productive medical claim audit process so your Practice may save unnecessary expenses.