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:
The Benefits of Internal billing and coding audits
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
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.