Financial audits have a significant impact on industrial growth. They are essential to ensure the proper management of money, adhering to calculations, and discovering areas where internal process improvements. Quality health care is also dependent upon accurate and complete clinical documentation in the medical record. The best approach to enhance documentation and the livelihood of your health care organization is through medical records audits. Physician medical billing staff must determine core areas to configure data storage and manage dataflow through medical audits.Medical audits provide an insight into required improvements and core competencies for the healthcare business and provide the following benefits;
Medical claims have a significant impact on the two areas of the healthcare industry;
- Medical practice
Medical billing professionals provide medical audits to implement such strategies that can improve healthcare administrative propagation and help to eradicate the cause of claim denials and poor collection management. It helps them to create clean claims and drive maximum reimbursement. In general, medical audits are also the critical factor that can help the physicians to monitor their financial growth and stay confident about their services’ quality. These audits can also help the physicians to observe and comply with the real-time data of their patients. Therefore, they can quickly provide quality patient care and leverage their bottom line.Although, it is a complicated task to manage medical audits and costly if not handled correctly. Generally, the medical claim audit is of the following types;
- Identify errors in medical billing.
- Adapt methods for improving medical claim recovery opportunities.
- Ensure a medical practice comply with the latest (and often byzantine) regulations governing medical claims.
There are the following options and benefits of a medical claims audit.
Types of Medical Claims Audits
An independent medical audit is managed by medical billing and coding professionals to identify problematic areas and omit out complications that hinder accurate medical billing. Therefore, medical billing and coding professionals would help to stop lost commercial opportunities and boost compliance with regulations. Medical audits also address a clear message to your medical billing and coding staff that you are committed to taking an active role in the process. It also ensures that every dollar is spent wisely and according to the regulations. Audits can be done irrespective of the size of your medical business and the number of employees on the medical staff. Medical audits should b performed regularly and committedly. There should be a properly planned schedule for medical audits to improve the medical claim process over a long time period. Medical audits could be prepared by using the following approaches; There are different approaches to such audits.
- Random Sample Audit:
- Comprehensive Audit:
- Hybrid Audit:
In a random audit, claims are selected based on the amount of money involved, and it covers both large and small claims. The main focus is on the dollar amounts instead of the number of claims. The results of a correctly performed random sample audit are statistically valid enough to be extrapolated across all claims. According to Texas-based HMS that is a consultant company for healthcare providers, the downside of the healthcare insurance companies is that they typically will not refund money based on the results of a random sample audit. As a result, these are best suited for discovering if opportunity even exists before moving to a more comprehensive review.
Larger in scope, a comprehensive audit looks at a specific group of claims both electronically and manually. The results of comprehensive audits are not meant to be extrapolated but, instead, deal only with the claims that are audited. However, such audits can lead to refunding money from claims administrators and in fact, that is often the focus of such an audit.
This audit is a combination of both the approaches; random sample and comprehensive audits. It helps medical billers to achieve the results of both primary recoveries of money and compliance with regulations. Such a review provides valid statistics on the accuracy of claims as well as the correct information required to seek recovery of overpayments.
Benefits of a Medical Claims Audit:
While the federal government has not mandated the medical audits, and only CMS encourages healthcare practitioners to perform audits. The CMS has designed a workbook to provide guidelines to conduct the self-audit to physicians. CMS also offers a host of reasons for the significance of the self-audits. CMS has listed the following benefits of medical audits;
- It ensures proper payment collection by reducing and preventing improper payment collection methods.
- It encourages an accurate claim submission process.
- It helps to improve the quality of patient care.
- Reducing the chances of an external audit.
- It prevents communication errors while interacting with your staff as they are responsible to report errors.
- Conducting a self-audit requires a thorough examination of the claim submission process within your healthcare practice, especially the areas of “risk” where errors are most often prone to occur.
- The audit provides insightful information for the documentation.
Most fundamentally, the findings of a self-audit must be reviewed by the physicians and acted upon to achieve the desired results.
Containing Cost, Ensuring Compliance
The primary benefit of any medical practice of a claims audit is containing and examining expenditures and revenue generation. However, a thorough claims audit can help to identify critical areas requiring new policies and improved procedures that will streamline the claims system as well as identify areas of cost savings. Medical billing and coding staff must provide a thorough audit and report each service rendered in ever visit. As it is already evident that there are benefits of a medical claims audit for a healthcare organization, and they are the most effective medium to ensure compliance with government regulations and to make the case of refunds from insurance providers.