So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call