Medical Auditing

What is medical auditing and why you should perform one

All areas of the RCM Process above are co-dependent on each other for successful reimbursement and a healthy practice.

Medical practice auditing entails conducting internal and external reviews of the RCM process to ensure you are running an efficient and hopefully liability-free operation.

These critical areas of the RCM Process can determine the reasons to perform medical practice audits:

  • A diverse payer mix
  • Determine if credentialing issues
  • Eligibility issues
  • Collecting accurate copays upfront; estimating coinsurance and deductibles and collection from the patient ahead of or at the time of service.
  • Accurate input of demographics
  • Pre-authorizations obtained
  • Accurate coding in a bell curve fashion with the proper documentation for support
  • Timely completion of notes by providers – within 48 hours of the date of service
  • Charges sent daily
  • ERA/EFT set up for all plans available
  • Accounts receivables worked on a regular cycle monthly with write off policies and procedures 
  • Full scale patient collection process with financial policy in place, pay plans, phone calls and regular cycle of statements
  • Regular monitoring and training as needed in the areas that are not meeting standards.

RCM Audit:

The scope of this service is designed to establish and deliver a Revenue Cycle analysis yearly for client decision-making purposes. This analysis is only for the client and will not involve any analysis of other provider TINS either operationally or of their patients.

  • Review of practice operations
  • Review of billing structure, revenue, and A/R.
  • Review of denials and write offs
  • Review of patient collections
  • Compare to national standards set forth by the MGMA

Should a practice audit result in potential coding issues, an in-depth coding audit should be performed reviewing codes in question.

Coding Audit:

Peregrine’s medical coding audit will include a select sample of patient encounters as coded and billed. Peregrine designs the audit identifying strategic initiatives, such as performance measures, validation of coded claims, prevalence of diseases, and treatments and adherence to policies and procedures to ensure overall compliance.

There are many goals in an audit:

  • Identify errors in provider documentation
  • Identify inefficiencies in payer reimbursement
  • Determine usage of incorrect medical codes, such as use of deleted or modified codes
  • Uncover areas of payer rules if medical practice billed inappropriately
  • Identify fraudulent billing practices, whether intentional or unintentional
  • Identify errors in claim scrubbers or claims software deficiencies utilized by the medical practice
  • Determine undercoding, overcoding, unbundling and lack of modifier usage
  • Address areas of risk that may prevent a visit from a Recovery Audit Contractor (RAC)

Detailed finding for both audits are present and trained on as needed with the appropriate staff and providers. Call us today for your auditing needs.