Auditing Presents Infinite Possibilities
A viable compliance program mandates the requirement to Audit the work performed within an organization. Auditing is an extremely broad field of view. Paragon’s auditing entails conducting internal or external reviews of medical record documentation, diagnosis, and procedure coding accuracy. Medical record documentation should be able to withstand the test of an audit. Compliance with standards of care is paramount. Procedural care, medical record documentation and accurate billing and collection processes should translate from the zero-defect care environment to revenue cycle performance. Insurance carrier performance and denial management are based on accurate and complete clinical documentation within the medical record. The best approach to improve your clinical documentation and the livelihood of your health care organization is through medical record audits. Audits are necessary to determine areas which require improvements and corrections. Medical record audits specifically target and evaluate procedural and diagnosis code selection as determined by physician documentation. Once areas of weakness are revealed through an audit, you can present the audit findings and identify opportunities for training in your health care organization.
Reasons to perform healthcare audits:
- To determine outliers before governmental and commercial insurance payers find them in their claims software and request an internal audit.
- To protect against fraudulent claims and billing activity.
- To reveal whether there is a variation from national averages due to inappropriate coding, insufficient documentation, or lost revenue.
- To help identify and correct problem areas before commercial insurance or government payers challenge inappropriate coding.
- To help prevent governmental investigational auditors like Recovery Audit Contractors (RACs) or Zone Program Integrity Contractors (ZPICs) from validating deficiencies.
- To remedy under-coding, up-coding, bad unbundling habits, inappropriate modifier use, and code overuse and to bill appropriately for documented procedures.
- To identify reimbursement deficiencies and opportunities for appropriate reimbursement.
- To stop the use of outdated or incorrect codes for procedures.
- To verify ICD-10-CM and Electronic Health Record (EHR) meaningful use readiness.
- To verify accurate government mandated incentive/disincentive program reporting – before fines and/or penalties are assessed.
Auditing medical records can be a time-consuming process, but the benefits far outweigh the inconvenience. Depending on the objective, medical record audits can be performed either by an external agency or by staff within an organization. Audits conducted by a third party are generally to review compliance, and internal audits are usually performed to evaluate current treatment processes and measure the quality of care. Please contact Paragon, so we can discuss how not create a viable auditing program for your organization. From one-off project work to on-going services, Paragon is here to help!
