Medical auditing entails conducting internal or external reviews of coding accuracy, policies, and procedures to ensure you are running an efficient and hopefully liability-free operation.
There are many reasons to perform medical audits:
- To determine outliers before large payers find them in their claims software and request an internal audit be done.
- To protect against fraudulent claims and billing activity
- To reveal whether there is variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
- To help identify and correct problem areas before insurance or government payers challenge inappropriate coding
- To help prevent governmental investigational auditors like recovery audit contractors (RACs) or zone program integrity contractors (ZPICs) from knocking at your door
- To remedy undercoding, bad unbundling habits, and code overuse and to bill appropriately for documented procedures
- To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
- To stop the use of outdated or incorrect codes for procedures
- To verify ICD-10-CM and electronic health record (EHR) meaningful use readiness