The Physician's Practice Side of Claim Auditing

Company Medical and Benefit Claims Auditing | TFG Partners


Auditing health care claims is a common management oversight practice for self-funded benefit plans because it's in their interest and required by regulations. But there's a growing interest in medical claim auditing services for physician's practices as well. Accuracy in billing works to the practice's advantage, along with the plan that is paying the claim. Capturing deserved revenue is crucial for a practice's financial health, and knowing the areas where coding and billing need improvement helps. On the flip side, it also helps with compliance requirements, and double-checking claims and billing is always wise.

If you're in a position where considering a claim audit makes sense, perhaps a rundown of the potential benefits will propel you into action. They include ensuring your practice's billing meets current regulations and industry standards and that your staff is coding bills correctly. It also flags errors that could cause liability issues and improves billing documentation. If you run an audit for your purposes, you're better prepared for the next one required for regulatory compliance. The audits review your claims to look for errors, and if you work with an audit firm, they can check each one.

Medical practices with someone qualified to handle an audit in-house sometimes still use the random sample method and review claims from a specific period. Auditors running sophisticated software can check every claim, and their accuracy is much higher than random sampling. But it can still be helpful if you have no other option. Nearly every audit uncovers errors that lead to the recovery of funds. For insurance plans, the goal is to flag overpayments. For physician's practices, it's the opposite, and under-billing is the issue of concern. When audits happen soon after errors are made, it's easier to correct them.

Today's audit reports are much easier to understand than in years before because of improved methods and greater accuracy. They are excellent staff education tools and can be shared with the people in your practice who handle billing. The most significant opportunities to recover funds lie in repeated errors that add up to substantial amounts over time. When they are corrected going forward, you'll see a natural increase in revenue for the same services you've always provided. The increased accuracy of medical claims auditing makes it a financial opportunity for all sides of the medical claims payment process.