Medical auditing is the critical examination of a healthcare organization’s performance. Almost any aspect of healthcare can be audited, but the majority of audits focus on payer reimbursement processes to assess compliance with payer guidelines and federal and state regulations. The medical audit plays an important role in a healthcare organization’s compliance plan by identifying errors and devising corrective actions to eliminate them. Medical auditing helps in maintaining compliant and profitable physician practices. More physicians intend to have audits performed on a regular basis, whether for Recovery Audit Contractor (RAC) audits, private payer denials, or simply peacefulness. The risks of failing to comply with documentation and coding are far too high. Noncompliance is costly. It costs federal and commercial payers, as well as programs that investigate, prevent, and recoup inappropriate payments. This cost is passed on to provider organizations in the form of paybacks and, in some cases, monetary penalties.

Medical Chart Auditing Procedures:

The only way to ensure coding accuracy is to compare it to the medical record material. The medical charts review, the most common type of healthcare audit, examines paperwork and claims information to assess whether claims have been properly recorded.

As the number of federal payer audits has increased, chart auditing programs have become important. Even commercial payers have set up teams to undertake on-site and off-site compliance audits of hospitals and medical practices on a regular and random basis.

When a provider organization conducts an internal audit or employs an independent auditor to conduct an external audit, it learns whether its claims will withstand government scrutiny. It also gets the ability to self-report and repair faults that represent a risk.

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The Importance of Medical Audits in Healthcare:

Medical audits serve as a mechanism to examine the level of care provided to patients, Educate providers on documentation standards, Check to see if the organization’s policies are up to date and effective,  Improve revenue cycle management,  Ensure that appropriate revenue is collected,  Protect oneself from federal and payer audits, malpractice lawsuits, and health plan denials. Medical auditing performed by or on behalf of the provider organization is critical because it prevents coding and billing errors. Audits not only detect incorrect coding but also prevent it from occurring again. Claim errors have a cumulative effect on an organization and, worse, invite federal scrutiny.

Medical auditing resolves ignorance by exposing areas of noncompliance, and ignorance is a liability. Consider the following to understand why the provider organization is responsible for detecting inappropriate coding and billing practices:

1.Widespread error pattern that results in higher reimbursement appears to be fraud and may be indistinguishable from fraud.

2.Widespread error pattern that results in higher reimbursement for the provider has the same effect on the payer as fraud.

The ambiguity of intent in habitual over coding and overbilling is accounted for by the laws governing healthcare fraud, most notably the False Claims Act (FCA). The FCA does not require a deliberate intent to defraud for prosecution and punishment.

Submitting a claim to Medicare or Medicaid is synonymous with certifying that you have earned the requested payment, as coded on the claim. The OIG emphasizes the FCA’s mandate, stating, “If you knew or should have known the submitted claim was false, then attempting to collect payment constitutes a violation.”

The key phrase is “should have known.” “It is illegal to submit claims for payment to Medicare or Medicaid that you know or should know are false,” the OIG reiterates. This means that you are legally liable for up-coding, double-billing, unbundling, failing to establish medical necessity, and a variety of other errors that would falsely claim you are owed money you did not earn.

What is the significance of medical auditing?:

Because penalties for violating the FCA can include fines of up to three times the program’s loss, plus up to $23,331 for each claim submitted in violation of the law, according to the 2020 regulations.

What Is the Role of a Healthcare Auditor?:

A medical auditor conducts internal or external audits of coding accuracy, policies, and procedures to ensure that an organization is operating efficiently and legally. Medical coding, medical terminology, clinical documentation, compliance, and regulatory guidelines must all be known to the auditor. Furthermore, the auditor must be able to determine the scope of an audit, perform the audit using approved tools, compile the data, report the findings, and provide corrective recommendations and staff training.

Most medical auditors have advanced training and are experienced medical coders. Auditors may work for an insurance company, a government agency or contractor, or a healthcare provider. Auditors play an important role in the financial success of the organization in the latter workplace by:

Lowering claim denials due to incorrect coding or insufficient documentation,Identifying outliers before payers request an internal audit of the practice, revealing differences from national averages due to incorrect coding, avoiding a RAC audit or requests from federal contractors for medical record documentation, Providing proper documentation to back up reported services and procedures, Detecting overpayments and avoiding false claims liability, Identifying reimbursement flaws.

After completing a successful medical coding audit, the auditor can share knowledge on how to resolve noncompliant billing activity. As a result, the provider and staff are better able to protect patients and achieve optimal reimbursement without fear of repercussions.

What are the most common types of healthcare audits?

In addition to random and focused audits, the following types of healthcare audits exist:

Prospective audits, also known as pre-payment audits, are performed prior to claim submission. Typically, the billing record (charge ticket or superbill) is obtained, along with any supporting labs, medication sheets, problem lists, and so on. If the documentation does not support the billing of CPT®, HCPCS Level II, and ICD-10-CM codes, the coding will be corrected based on the audit findings. This type of audit may have an impact on claim processing time. The audit should be followed immediately by communication between the provider and the auditor. A prospective audit can be either random or targeted.

Retrospective audits look at medical record documentation after the provider has submitted the claim to the insurance carrier and received payment. The billing record (charge ticket or superbill), the Remittance Advice/Explanation of Benefits, and the medical record documentation, as well as other supporting documentation, will be reviewed by the auditor. A retrospective audit may result in a refund or partial payment to the insurance carrier.

Aggregate Analyses: An aggregate analysis is useful for comparing data from a specific data set. The organization can identify areas of concern, such as under-coding and up-coding trends or utilization frequency, by comparing coding data among providers, both within a practice and from another practice of the same specialty.

Rebuttal Audit: In rare cases, a rebuttal audit is conducted in response to a payer audit with the goal of validating or refuting the payer’s conclusions. A rebuttal audit’s work focuses on determining whether the appropriate binding standards were correctly applied, or whether the information provided to the payer was complete and correctly interpreted.

What is the distinction between a medical billing audit and a medical coding audit?

A medical billing audit, also known as a revenue cycle management (RCM) audit, is more comprehensive than a medical coding audit. The billing audit combines a medical record audit as well as an evaluation of the entire billing cycle — from copay collection processes with insurance verification and to claim submissions, payment posting, follow up, and with denial and appeals processes — and is designed to optimize RCM performance.

Obtaining a CPMA credential demonstrates that you have:

• Medical documentation, fraud, abuse, and penalties for documentation and coding violations based on governmental guidelines
• Coding Concepts
• Scope and Statistical Sampling Methodologies
• Medical Record Auditing Skills and Abstraction Ability
• Quality Assurance and Coding Risk Analysis
• Communication of Results and Findings
• The Medical Record

AAPC  CPMA New Exam Structure:

• 100 multiple-choice questions (proctored)
• 4 hours to complete the exam
• Open Code Books (manuals)
• 70% passing score required

Mode of Training

• Online
• Classroom

The majority of the questions cover auditing theory, legal and regulatory issues, NCCI, RAC audits, statistical sampling, coding concepts and modifiers, and so on. Furthermore, each test taker will be required to audit approximately 18 health care cases.