Importance of Billing and Coding Audits

Healthcare coding & billing processes and workflows if not effectively programmed can be disastrous to the revenues of physicians and healthcare providers. For an effective and efficient Revenue Cycle Management (RCM) process, internal as well as external auditing is essential. Moreover, being compliant with healthcare regulatory programs assumes significance if under investigation for inconsistencies is observed by the healthcare regulatory offices. Today nearly over 10 audit and fraud prevention programs are being conducted by the federal government and quality organizations along with private payer requests HIM (Health Information Management) departments. The need for medical billing and coding audits assumes great significance against this environment to prevent abuse, wastage and fraud of the system.

Coding & billing errors lead to claim denials due to:

• over or improper payment
• lack of verification and eligibility of patient's details
• wrong application of diagnosis, service, and/or procedure codes
• lack of medical documentation.

The Benefits of Internal billing and coding audits

• Improve Coding accuracy
• Identify causes for coding errors
• Decrease the variance and increase reliability
• Highlight strength and weakness in the processes and workflows
• Streamline proper charging towards Insurers for medical services rendered
• Increase timeliness of payment and co-ordination of benefits

Thus, practitioners are required to be more vigilant when designing their coding and billing compliance policies so as to be in accordance with regulatory guidelines and industry standards.

Both internal as well as external audits besides strengthening the regulatory guidelines, also bring in many more benefits

• Enhances healthcare providers & organizations to optimize their claims process, thus mitigating coding and billing risks.
• Improves the automation and speed of the various processes and workflows, enhancing cost efficiency.
• Enables healthcare providers to highlight consistent patterns of coding and billing errors, and thereby initiate better training programs on claims which focus on more stringent coding and billing.
• Augments the need for improved document and data management,
• Initiates the need to implement the tracking of audit patterns by using advanced trend analysis.
• Highlights the need to design and implement appropriate corrective action and preventive action processes, in accordance with the audit findings.
• Prepares healthcare organizations and providers to make better strategic decisions with enhanced reporting and analytics that can provide valuable business insights.
• Provides for a comprehensive analysis of medical claims imperative to identify fraudulent activities.
• Ensures medical organizations and healthcare providers are up to date on requirements, documentation, timelines, and vulnerabilities within their system.
• Improves the appeal process making it effortless, if and when claims are denied or rejected.

Medical billing and coding audits improves and strengthens the overall coding and billing processes, ensuring a more stringent claim process, and certifies that the right safeguards are in place to avoid future errors, thereby also ensuring a more healthy Revenue Cycle management (RCM) process enabling higher revenues.

The OIG (Office of Inspector General) stated that: "The best evidence that a provider's compliance program is operating effectively occurs when the provider, through its compliance program, identifies problematic conduct, takes appropriate steps to remedy the conduct and prevent it from recurring, and makes a full and timely disclosure of the misconduct to appropriate authorities."

Thus a strong team should be comprised of the following participants: the compliance officer, the CFO, case management, IT, a physician advisor, and HIM to ensure not just to meet the regulatory compliance but also streamline its processes and workflows to ensure better profits with a more stringent and vigilant claims process.

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Published By - Medical Billers and Coders
Published Date - Sep-26-2016 Back