Enhancing productivity in clinical practice — How crucial is a Medical billing audit?
A successful and profitable clinical practice is a combination of two things — one, your professional expertise in rendering patient care, and two, flawless administration and practice management. When these two aspects come together, you will see your productivity, revenue and reputation skyrocketing. However, when there is discord in either of these two, the system can collapse easily. Many times, even when you do everything on your part to provide the best care possible, errors in data submissions and claims delay the payment cycles. It easily disrupts the very equilibrium of your practice. This is when conducting a medical billing audit is crucial. Auditing can be:
1. Internal
Where a group of efficient and experienced individuals within the company are designated to conduct an audit by accessing all the records, whenever necessary. This can be done frequently without disrupting the day-to-day clinic activities and also they will have a better understanding of what data is available where and how things are run in the organization which makes the process easier for them.
Most of the big clinical organizations have a medical billing audit team to conduct these audits and compliance checks regularly to improve productivity.
2. External
Is usually conducted annually, where the clinic hires a professional external auditing team to ensure accuracy in their billing practices. These professionals also verify whether your coding practices are up-to-date and billing policies are compliant with the current norms.
It gives you a good chance to evaluate your overall practice objectively and make the necessary corrections.
Who is a professional auditor?
It takes a certified professional; who is also a compliance auditor/certified medical auditing specialist to fill in that role. The auditor will be somebody with a business/finance degree or degree in clinical/health service administration or medical record keeping. Most of them are likely to have some experience in coding and can review health care records, billing documents, administrative documents and coding compliance. He/she must be aware of the current regulations in the industry to assure quality.
The auditor should be able to analyse the records objectively, ensure confidentiality and organize the process effectively. He/she should have first-hand knowledge of medical terminologies, MS Office applications, data entry and ICD/CPT coding protocols. Compliance with HIPPA is mandatory; the auditor should be a member of the American association of medical audit specialist’s forum as well. There is a written examination to qualify and get certified as a medical auditor.
Steps in auditing
1. Audit of patient demographics and healthcare records
Often the patient information inputs in the hospital server show errors, which can significantly delay payment cycles. Audit runs through the clinical records, diagnostic records, lab tests and radiograph reports to look for errors or disparities in data.
2. Auditing to find missing information
Auditing is done to make sure all the diagnoses, disease conditions and treatment rendered are duly documented since any missing data in these will exclude them from the billing process, which ends up in no payment or underpayment for the valuable service provided.
3. Audit for coding compliance
One of the important areas scrutinized during a medical billing audit is coding compliance. If a bill is wrongly coded or under-coded, there will be a financial loss. If it continues to happen frequently it can result in a huge gap in the revenue. If the over-coding of bills happen by mistake and get caught by the authorities, a penalty or return of money can be demanded by the payer. This is why error-free coding is of paramount importance.
If gaps are found regarding coding compliance, training the clinical staff on up-to-date coding practices will undeniably increase profitability.
4. Auditing the billing process
All sorts of finance records, receipts, invoices, ledgers, policy documents and charge sheets will be looked at for possible errors. The data provided in the health record is cross-matched with that in the billing documents to find out if they follow the appropriate medical/provider policies. In case of inappropriate billing policies being followed, they are rectified, modified and brought into practice.
5. Revenue cycle audit
Gives you an idea of how efficient or inefficient your current revenue cycle management is. The fee schedule, submitting claims and time taken for receiving payment as well as denial management protocols implemented in the typical clinical set-up can be improved and made much more productive; given the trend and root causes of problems are charted and plotted. Any kind of fraud happening in the system too can be brought to light at an early stage if an audit is conducted periodically.
Medical billing audits can pinpoint the blunders being practised unknowingly in any clinical setup. Once these errors are listed it is easier to resolve them by implementing new controls and practice patterns. It could be a new beginning to achieve the practice of your dreams.
