The Importance of Revenue Cycle Auditing in Healthcare

A healthy revenue cycle auditing system is imperative for the correct functioning of a healthcare organization, whether that is an office-based practice or a hospital. According to a 2022 analysis of CMS data on claims and appeals, 18% of in-network claims were denied, with some plans reaching as high as 80%. In addition, these denials are rarely appealed and when they are, insurers normally uphold their decision. This situation leads to massive revenue losses for healthcare providers. A denial of a medical claim is a loss by definition, and appealing entails a new investment with low chances of recovery. This said, revenue cycle auditing is a powerful tool for organizations to ensure compliance and avoid getting their claims denied. Not only that, it is also a way to maintain a motivated and engaged staff. In this article, we will share just how establishments can benefit from a healthy revenue cycle auditing system.

Revenue Cycle Compliance

The healthcare regulatory environment is in constant change. In order to carry out a successful revenue cycle audit, there are three steps: 

  • Regulation monitoring. This is where the auditors check if the systems align with the OIG’s General Compliance Program Guidance.
  • Auditing process. It is important that there is a review methodology in place that includes clear communication about the findings and recommendations.
  • Staff training. This step is critical when moving forward. Training staff so that they are knowledgeable of the regulatory changes not only impacts the bottom line, but it increases job satisfaction as employees feel that they can grow when in the know.

A well-executed revenue cycle audit program that focuses on compliance seeks to avoid making mistakes that can lead to being penalized for fraud or more under State or federal laws like: the Health Care Fraud Statute, the False Claims Act; the Anti-Kickback Statute; the Patient Access and Medicare Protection Act, Exclusion Provisions, and the Civil Monetary Penalties Law.

Identifying Coding Issues through Revenue Cycle Auditing

Coding in healthcare is ever-evolving, making it difficult to keep up with the changes. This is precisely why organizations and providers alike hire coding experts to assist with such processes and obtain the correct reimbursement. The best way for organizations to protect their revenue is to comply with regulations so that their claims aren’t denied. Expert coders are integral to the billing process. However, it is even hard for the experts to fully adapt to the changes due to the high productivity demands. By instating regular revenue cycle auditing instances, the organization can learn where their pain points are and streamline their processes. 

Related: The 5 Steps of Successful Revenue Cycle Management

Auditing Recommendations

In order to carry out effective revenue cycle audits, there are a few steps that cannot be overlooked —or overstated.

Periodically Conduct Revenue Cycle Audits

It’s no use performing a revenue cycle audit once a year. Changes happen at a much faster pace and systems tend to stagnate if not revised on a regular basis. Therefore, staff members, especially coders, need to be in constant communication with auditors in a way that is open and transparent in order to achieve the best results. 

Set a Standard for Procedures

When establishing an audit, the organization should lay out the specifics of the procedures so that everybody knows what to expect. This is one of the principles of project management, and it applies perfectly to this scenario. The more employees know, the more collaborative they will be. They should know who they will report to, which charts and processes will be reviews and what the expectations are.

Communicate Clearly

In line with the previous recommendation, both coders and physicians need to know that compliance is an intrinsic part of their everyday tasks. They should expect audits and understand that these are not intended to point out faults and subsequently punish staff, but to carve a path of continuous improvement and wellbeing of the organization as a whole. A healthy revenue cycle benefits everybody involved.

Auditing Success with Peregrine Healthcare

Peregrine Healthcare strives to help healthcare facilities and providers offer the best quality of services, which inevitably leads to better reimbursement and a healthy revenue cycle. Our world-class expert auditors offer confidence to our clients, as we go through the whole process side by side. Peregrine Healthcare knows first-hand how much everybody’s time is worth and we foster healthy practices, aid growth and drive patient satisfaction.

Contact us for more information about our auditing services and how we can tailor them to your needs.

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