Self Auditing Medical Claims
Using human logic during your review to identify medical claims with the highest likelihood for improper payments can be a challenge. There is an old adjuster?s motto, ?If it isn?t in the file, it didn?t happen.? Be aware that the number one area of problematic claim coding found by Claim Risk Adjusters is located under the Evaluation and Management documentation.
Identify and name your Auditing goals like:
- Identification of payment errors and opportunities for future cost savings
- Prevention of human misinterpretation of plan language
- Fulfillment of due diligence and responsibility
- Optimize claim paying performance by uncovering root causes of errors
An Audit Process includes:
? Investigating five charts per provider, and rotating each provider every week.
? Involving a comprehensive review of medical records, documents, hospital records, provider contracts, billing histories, fee schedules, and medical claims, to thoroughly investigate coding and billing procedures.
? A result letter including a claims report documenting all findings.
? Taking proactive action to correct and prevent coding, billing, other compliance shortfalls and conducting a baseline audit of your practice does require a considerable effort.
? Verification of the guidelines in the provider?s documentation and reporting the appropriate level of service for services provided are part of audits. There will be less risk for error and concern when a provider understands Evaluation and Management documentation guidelines and practices compliant documentation. Audits look for a medical record to be complete and compliant for patient care.
Following points should be considered while ensuring the records are complete and compliant:
? The patient signed all the necessary forms and consents.
? The physician documents risks and benefits of recommended treatments.
? The service needs an order.
? The procedure note is adequately documented
? The physician has signed the record.
? The patient has signed an ABN (advanced beneficiary notice).
Common errors in coding and billing while auditing:
Points that can pose substantial threats to physicians are by ignoring
? Coding and billing criteria
? Documentation standards
? Benefits requirements
Problem areas include:
? Failing to attach the right codes to various diagnoses.
? Not documenting the patient’s chief complaint.
? Wrongly coding an office visit as a referral and not a consultation
? Unbundling or billing each component of a multiple component service as a single service
? Manipulating billing by adding items and services
? Submitting unreasonable claims for equipment and medical supplies
? Upcoding the level of service provided
? To enjoy better financial increments and failing to properly document medical records.
Challenges in Auditing:
Complex Data Analysis
With an enormous number of medical claims in a year the task of choosing sample claims to conduct an audit can be tedious and complex to medical practitioners. Claims with the highest probability for error are chosen as part of the audit sample.
Review of Medical Record Documentation
If medical records documentation and selection of appropriate codes do not match medical bills, the medical claims are termed as false claims.
Time-consuming Manual Documentation
Many healthcare providers follow a manual documentation system that is time consuming. Auditors have to conduct extensive reviews of billing forms and the application of diagnosis, service, and procedure codes. Computer logs also need to be checked periodically to detect discrepancies in coding and billing patterns.
Complex Appeals
Appeals for claims audits go through several stages with many stakeholders involved. It is:
? Demanding
? Resource-intensive
? Expensive and
? Requires thorough, clean documentation.
Finally, many health providers feel threatened by the appeals process even though they have a good chance of winning back their payments.
It may be worthwhile to consider outsourcing or hiring an expert service to preform the auditing of your practices medical claims.