Avoid Medical Billing Issues with a Self-Audit

You can set up what you believe are foolproof systems, but until someone tries to hack their way in, it’s impossible to know where the flaws are. The same holds true for medical billing issues. You really don’t know where the problems are unless you come at it from the perspective of an auditor. The good news is that the process is fairly straightforward. By conducting a medical billing self-audit, you can discover all the weaknesses in your system so they can be shored up.

Step one is to select a group of charts to examine from within the last six months. They should be a mix in terms of physicians, dates, and government payer/private payer.

Step two is to examine those records for the following:

1. Information gaps. Look for places where information is missing or insufficient. Patient demographics, history, examination details, and diagnosis should all be present. One common error is omitting the chief complaint in the history portion of the record. For example, recheck or follow-up cannot be the chief complaint—you need more documentation than that. This is also a good time to inspect for missing lab or pathology reports.
2. Poor documentation. Check to see whether or not the documentation supports the diagnosis code and level of services provided.
3. Incorrect coding. Review the codes assigned and the bill sent to the payer to see if they were (1) in agreement with each other and (2) in compliance with the payer’s requirements.

On thing to keep in mind when beginning a self audit is making sure everyone reviewing records is using the same process. They should be given a checklist so they each look for exactly the same information each time they review a chart.

Of course, the logical outcome from any self review is to revise your procedures. Ideally, this involves conducting a root-cause analysis on each type of issue you uncover. Trace the problem back to its beginning and look for ways to mitigate it. For example, a physician may need to review a certain set of ICD-9 codes to correct a pattern of under-coding. Similarly, billers may need additional training in areas where mistakes are frequently occurring.

Happily, conducting your own medical billing audit once or twice a year can not only help you prepare for a possible external audit, it can uncover billing issues you can resolve to improve claims acceptance and, thus, cash flow.