How to avoid returning revenue to health insurance carriers during an audit

With that being said, as a Coder/Biller in the the health care industry from the revenue cycle aspect (business side), I have witnessed first hand health insurance carriers recouping revenue from providers from an audit, which could have been prevented, as long as the health care provider follows the billing rules and guidelines.

Here's are a few tips to avoid payers recouping revenue during an audit:

Always be Audit Ready

When I conduct medical billing training's for health care professionals or clients, I state " you must always be Audit Ready", because you never know when you will receive a letter in the mail. Being audit ready aligns with avoiding returning revenue to health insurance carriers for your services. Tiffany Haddish voice "She Ready"

Create a Medical Billing Policy and Procedures

  • Creating a policy and procedures of your billing processes will help you and your staff of preventing billing errors. Yes, we are all humans and mistakes happens, but they cannot be continuously. Insurance carriers may identify that as FRAUD.

  • Include in your policy and procedures the steps of when the billing process begins (which is during the patient check-in to the patient checks out process).

  • Include step by step illustrations of the your EMR system ( visual experience)

  • Indicate your self-pay process

  • Note an auditor can request to view your policy

Billable Encounter Notes

Health care professionals keep in mind you signed a contract stating you agreed to follow billing rules and guidelines. And remember encounter notes are legal documents.

  • All insurance carriers requires the following elements in each encounter notes.

  • Date - start and end time

  • Incident 2 rule if performed- Supervising Signatures & Rendering signatures

  • Addendum- if applicable

  • Medical necessity- reason for the visit ( why the patient needs your services)

  • Correct Diagnosis codes must support documentation

  • Correct CPT selected for services rendered

  • Avoid Contradictions

  • Spell check your encounter notes ( legal documents)

  • Avoid cloning copy & paste encounter notes

  • Each note documentation must be different for each date of service ( 🚩red flag- all notes states the exact wording)

Received Audit Letter

  • Don't panic! Prepare the requested charts for auditor.

  • Review all encounter notes ensuring all element (see above) are documented in the encounter note.

  • Do not alter any encounters notes. Remember EMR systems are date & time stamped and no handwriting for billed services. (🚩red flag- typed notes to handwritten)

  • If you need to mail your encounter notes ( please submit certified mail)

  • If the auditor comes on site -prepare your office or a quiet location for the auditor to review charts. Have some beverages coffee, tea , soft drinks and snacks for the auditor (hospitality).

Health care professionals may feel overwhelmed or no direction of where to begin when they receive audit letter. As long as you follow the steps above, you may not be liable to return monies back to health insurance carriers. Insurance carriers & auditors want to ensure you are compliant with the billing rules and guidelines to avoid waste, abuse and fraud.

Health care professionals if you do not feel confident to go through this process alone. POST & CLAIM, provides auditing services to health care professionals. Click here to receive a 30 MINUTES COMPLIMENTARY AUDIT CONSULTATION. We understand your goal is to maintain sustainability and is not in the business of returning revenue to payers for rendered services.