Billing audit services are the least utilized tool in the healthcare revenue cycle. All practices do collections reporting, but few do audits of how much of that revenue is 100% reflective of the work that was performed. Billing Audit Services answer, and the results are always significant.
What Billing Audit Services Actually Examine
A complete billing audit examines coding and the use of modifiers, documentation of services, claims submitted, and denial rates over a specified timeframe. Each aspect is assessed according to the latest payer rules and CMS requirements to detect errors that could be stealing revenues. The result is not a report of errors but of where to focus efforts to capture missed revenue.
Billing audit services also perform a work compliance analysis, looking for patterns of over and under-coding that may trigger a payer or OIG audit. Billing audit services allowing practices to identify these patterns themselves are in a much better spot from a compliance perspective than practices that await a payer or OIG review to find the same opportunities.
Prospective Billing Audit Services and Clean Claims
Prospective billing audit services happen prior to claims submission. The initial layer of review identifies miscoding, missing documentation flags, and omissions of modifiers that result in denials. The implementation of prospective auditing is a predictor of a practice’s clean claim rate and speed of payment.
The benefits of prospective billing audits quickly add up. Each denied claim prevents the time and money spent reworking denials. Large practices with high volume account balances see increases in net collections in the first billing cycle with even small increments in clean claim rate.
Retrospective Billing Audit Services and Compliance Protection
Retrospective billing audit services review already filed and paid or rejected claims. Such an audit identifies systemic errors in coding that have been accumulating over time to adversely affect revenue and compliance issues that need to be addressed before the payer finds them. Insight gained from retrospective audits drives the process and standards improvements that help avoid future errors.
Regular retrospective billing audit services help practices develop a compliance culture that shields them from external audits. When gamed or audited by a payer and/or regulatory agency, internal auditing provides evidence of due diligence and accountability that is heavily weighted during the audit process.
Home Health Billing: Where Payment Model Complexity Drives Revenue Risk
Home health is billed under the Patient Driven Groupings Model (PDGM); a prospective payment system that pays claims based on patient groupings that are determined at the beginning of each 30 days episode of care. The Home Health Billing process requires sequencing of diagnoses, complete OASIS assessment information, and appropriate documentation to support the clinical group. If there are mistakes here, it impacts reimbursements for the entire episode.
Diagnosis Sequencing in Home Health Billing
Home health billing episode classification is based on the primary diagnosis. When the order is wrong, the episode is reimbursed at a lower level than it should be, given the services provided. It is later difficult to recover that lost revenue, especially in a timely fashion.
Home health billing also requires coding of comorbidities. Home health patients often have multiple, active diagnoses, and the medical record should capture all significant comorbidities that contribute to the weight of the case mix. A lack of comorbidity capture in the claim results in your practice billing as if you’re caring for a patient with a lower level of complexity.
OASIS Accuracy and Its Effect on Home Health Billing
Every home health episode of care begins with an OASIS assessment. The clinical and functional status reported on OASIS is the basis for patient grouping and payment rate received. Incomplete or incorrect OASIS assessments result in lost payments, which are one of the largest sources of lost income in home health care, and they begin with clinical documentation.
Bringing consistency to clinical documentation, as it is used for home health billing, is an effort that includes field clinicians and billers. When clinicians know how their documentation impacts reimbursement groupings, the OASIS data are more accurate, groupings are accurate and reflect the complexity of care, and the agency receives what it is entitled to receive on every episode of care.
Audit Discipline and Billing Expertise Working Together
Billing audit and home health billing each require a rigorous degree of technical accuracy, which can produce substantially different results when applied. Med Brigade specialists can provide expertise to both disciplines, helping agencies and practices to appropriately diagnose payment loss, correct systemic problems, and optimize their billing operations.