A medical claims audit is a valuable tool for your clinic’s compliance. It can improve the accuracy of your claims and make medical billing more efficient. In addition, you can do the audit internally or hire an external auditor, but knowing how to audit medical claims is essential.
Start by simplifying your claims process using a trusted clearinghouse to ensure a smooth audit. Now let’s take a closer look at the claims auditing process and how medical claims software can help make your audit successful.
Why should you schedule a medical claims audit?
To start, let’s explore why scheduling a formal review of your medical claims and appeals is beneficial before we discuss the main steps of a medical claims audit. Here are a few essential reasons why you should conduct regular audits on your medical claims:
- Check if you’re following the latest industry rules and regulations.
- Make sure your staff is using the correct codes for health services.
- Identify mistakes that could put your organization at risk.
- Improve the accuracy of documentation and reporting.
- Get ready for mandatory industry audits.
What are the main steps in a medical claims audit?
Some might find the word “audit” scary, but a medical claims audit is simply a thorough check of some of your claims to see mistakes. If you decide to hire Medical Billing Services in Illinois for an audit, the chosen agency will explain the audit steps and inform you about the necessary documentation. The following seven steps will guide you if you’re conducting an internal audit and need help knowing where to begin.
Step One: Form your claims review team.
To conduct an internal claims audit, choose a team member to supervise the process. You might need multiple team members if you have many claims to review.
If you need more internal staff with audit experience, consider hiring an external audit team. When using external auditors, follow their instructions and proceed to Step Six.
Step Two: Select a sample of your medical claims.
After identifying the person in charge of your audit, the next step is to determine a specific time period for the audit and gather a sample of your current claims. For instance, you can choose to review claims from a specific week, month, or quarter. The sample size will rely on the number of providers within your practice.
Step Three: Reviewing Claims for Accuracy
Now it’s time to examine each claim for accuracy carefully. This step is crucial and may take a while, especially if you have a large sample size. First, gather all the necessary documents for each claim, including clinical records and financial information like payment receipts.
Once you have all the relevant documents, start reviewing the claim. Check if the data provided by the Primary Care physician or doctor of another specialty is correct. Look for any coding mistakes, such as undercoating or overcoming them. Lastly, go through the claim meticulously to ensure that you’re following the current policies and standards.
Step Four: Identify and record mistakes and discrepancies.
As you conduct your audit, you may discover errors in medical billing that can significantly affect your revenue. It’s crucial to create a list of each mistake and discrepancy you find. This will help you adjust your claims procedures accordingly. While each practice is unique, here are some common errors that can increase the number of denied claims:
- Incorrect identifying information, such as address errors or wrong birthdates.
- Failure to request or follow up on necessary pre-authorization.
- Differences between diagnostic codes and treatment codes.
- Outdated policy information for the patient.
- Providing services that were not medically necessary.
Step Five: Report Your Audit Findings
If you decide to conduct an internal audit, make sure your lead auditor writes a clear report documenting all the findings. While there are no strict rules for audit reporting, include these important sections in your report:
- Executive Summary: Give a brief summary of the audit results.
- Audit Scope: Specify the size of the sample and the time period covered by the audit.
- Findings Summary: Provide an overview of the strengths and weaknesses identified.
- Corrective Actions or Recommendations: Suggest ways to reduce errors and oversights.
Step Six: Discuss audit findings with your staff.
After receiving the audit report, it’s important to go over the findings with your team. It’s recommended to involve the entire team in the review, but give extra attention to employees who handle claims regularly. During the review, focus on these three points:
- Share specific examples of common mistakes that happen repeatedly.
- Clearly explain the effects and outcomes of these errors.
- Encourage your staff to provide feedback and actively participate in the review process.
Step Seven: Creating a Plan to Fix Problems
To make the most of your audit findings, it’s crucial to create a plan that addresses common mistakes and areas of weakness. Further, Your goal should be based on the audit results and the issues you identified.
For example, if the audit shows that all the doctors in your practice are using outdated codes, it’s a sign that you need to update their training. You can also schedule a training session to cover the latest coding guidelines.
Key Takeaways:
- A medical claims audit is crucial for clinic compliance and improving claims accuracy.
- Simplify the claims process using a trusted clearinghouse for a smoother audit.
- Regular audits help ensure compliance with industry rules and regulations.
- Audits help identify coding mistakes and minimize organizational risk.