Wiki Auditing when a Billing Service is in place

[bethdeak]

Hi all,

I may be working on a physician practice audit for E/M auditing, and billing accuracy and compliance. I've just been made aware that they outsource a portion of their billing to a third party billing company. I've been looking through my resources for how to approach an audit in this scenario but I'm not finding much.

Does anyone have any feedback or suggestions they can offer?

Right now I'm wondering if it's just reviewing the accuracy of the E/M code billed by the provider and then tracing it through the billing service for accuracy in billing, denial management, and posting?

Thanks for your suggestions,

 

[thomas7331]

At one of my previous jobs, I worked with an outside audit firm that was hired to evaluated our coding. For each sample we provided, they asked for the medical record and a copy of the final claim that was submitted and audited based on whether or not the claim was supported. I think it's a good approach in this situation - the first step should be to ensure that the claim, which is the final product, is accurate. What happens between the documentation and the claim is part of a practice's internal process - if it's discovered during audit that the claims aren't accurate, it's going to be the practice's responsibility to determine the next step to find out where the breakdown is happening and how to fix it. Unless they've asked you to evaluate the whole process from start to finish, I'd just evaluate the coding from a claims accuracy point of view.

 

[bethdeak]

Unfortunately, what they are looking for is a billing, coding, and compliance risk assessment/audit.

I'm just not entirely sure how to work in the portion that leaves the practice by the billing company and how willing they are going to be to work with me on it.

My approach was going to be review the super bill, the chart, ensure the documentation correlates, and then review what was finally billed by the billing service. I'm just worried this is going to unnecessarily blow up huge because of the add in of the billing department.

 

[thomas7331]

I agree that could put you in an awkward position. But the practice you're auditing is the billing company's client, not you. In that position, I would not want to deal directly with the billing company - you should be able to tell the practice what information you need to conduct your audit, and the practice should obtain it for you. Otherwise if they do require you to go to the billing company to review anything, I would recommend minimizing the interaction with them to just going in, getting the information you need, and leaving. It's up to the practice to work with their own contractors - it shouldn't be part of your responsibilities and I personally would want to avoid getting into the middle of their relationship.