As a future medical coder or reimbursement specialist, you may find that auditing is part of your regular job duties. There are different types of audit processes that may be used by a medical practice. For internal audits, this may be prospective or retrospective reviews. If the auditing is being completed by an external party such as a third-party payer or designee, then pre-payment or post-payment audits will be conducted.
Explore the main types of audits performed with best practices for doing so.
Include the following aspects in the discussion:
· Identify the pros and cons of the prospective and retrospective audit process.
· Highlight reasons why it is best practice to conduct internal audits.
· Describe why external audits may be conducted.
· Discuss your interest in auditing as part of a medical coder or reimbursement specialist duties. Is this a skill that you feel would be advantageous?
Best Practice for Internal Audits
It is best practice to conduct internal audits because they are the foundation of an effective compliance program.
Proactive Risk Mitigation: Internal audits demonstrate to external regulators and payers a commitment to compliance and ethical billing practices, significantly reducing the likelihood of severe penalties should an error occur.
Optimized Revenue Cycle: They ensure the practice is accurately capturing all revenue it is entitled to (preventing undercoding) while simultaneously preventing fraud or abuse allegations (preventing overcoding).
Focused Education: Audits provide tangible data to tailor training programs for providers and coders, ensuring documentation supports the codes selected.
External Audits and Their Rationale
External audits are performed by third-party organizations (such as Medicare/CMS, commercial payers, or their designated contractors like Recovery Audit Contractors - RACs). These are generally categorized as pre-payment or post-payment.
Sample Answer
Auditing is a crucial function in medical coding and reimbursement to ensure accuracy, compliance, and financial health. Understanding the different types of audits—internal (prospective and retrospective) and external (pre- and post-payment)—is essential.
Main Types of Internal Audits
Internal audits are performed by the healthcare provider's own staff (coders, billers, or dedicated auditors) to ensure accuracy and compliance before claims become subject to external scrutiny.
1. Prospective Audit (Pre-Billing Review) 📝
This review is conducted before the claim is submitted to the payer.