Silent billing errors like undercoded E/M visits, missed charge captures, and 835 ERA payments that land below your contracted rate, quietly drain revenue. Without a dispute, these underpayments close permanently as CO-45 contractual adjustments, money your standard AR reports never flag.
Our medical billing audit services, led by CPMA-credentialed auditors, run a full-scope review across coding accuracy, documentation integrity, and contract compliance, pinpointing the exact revenue leaks that silently slip through.
A medical billing audit service is a systematic review of your claims, code decisions, clinical documentation, and payment processes to find medical billing mistakes, compliance problems, and money that you earned but did not receive. A dedicated medical billing audit company allows practices to have CPMA-certified reviewers work with them who are exclusively devoted to audit methodologies, not daily claims processing. This distinction is important because onsite billing staff normalizes the errors by doing so, while the RCM audit measures the difference between what was billed and what should have been billed.
If your practice bills Medicare or Medicaid more than 30% of your overall claim volume, billing audits must be done in accordance with compliance regulations. The OIG has identified seven elements of an effective compliance program; periodic independent review is specifically required. When a MAC or RAC contractor requests records, the first question is whether an audit history exists — and what corrective action followed.
When coders are under time constraints, they typically default to Level 3 coding on encounters that should be coded as Level 4. This incorrect coding leads to incorrect payment amounts at the wrong rate and goes undiscovered for months, even though multiple denials of service documents have gone out.
The RAC and the MAC have the ability to review post-payment claims for at least three years after they're paid. Therefore, a documented audit trail can be the most reliable defense against potential escalated penalties due to violations of the False Claims Act.
Most commercial payers underpay approximately 7 - 11% of claims that are paid based on contracted rates. Many of the claims are posted as adjustments and closed without verifying the amount owed by the payer. A payer-specific audit provides an accurate representation of what each commercial payer owes in claims.
A targeted medical billing error audit surfaces billing patterns that pass every payer edit and appear correct until documentation is reviewed against the claim. These are the errors encountered repeatedly across practice types.
Beginning January 2023, CMS mandates that the provider who performed most of the work must be listed on the claim; however, many practices are continuing to use the physician's NPI as a default. The claim pays; the False Claims Act exposure surfaces when a Medicare contractor pulls records.
Medicare deleted modifier 59 and replaced it with the four 59 — XE, XS, XP, and XU — when billing for NCCI-restricted procedures. Practices that have not revisited their modifier logic since 2015 are using 59 instead of XS or XE. Pays on first submission; triggers repayment on MAC post-payment review.
Billing for services rendered in a facility at location 11 will trigger payment based on the non-facility reimbursement rate, which is 11% to 19% above the facility rate. Payer audits recoup the differential across a 2–3-year look-back. Present in nearly every hybrid-model audit.
Incident-to requires the supervising physician to be physically present in the office suite and immediately available. Practices get it right in policy, but miss it in practice when the physician steps out. Reimbursement difference versus NP or PA's own NPI: ~15% per claim under Medicare Part B.
MAC billing includes a patient's base units plus time units, in which one time unit is usually considered one for each 15-minutes. Billing 3 units for 47-minute cases instead of 4 leaves revenue on every sedation case. At 30 cases per day, the discrepancy compounds across a quarter.
Each engagement is scheduled to align with your exact risk level. Below are the eight review areas that will be included in Nexus io's medical billing auditing services. These review areas cover areas including medical coding audit services, claims audit services, documentation integrity, and AR recovery. These audits can either be standalone engagements or integrated with a complete revenue cycle audit.
This audit focuses solely on E/M level selection using the CMS 2021 documentation guidelines. The audit also evaluates the coding accuracy of ICD-10-CM code specificity and HCPCS Level II codes, along with the assignment's accuracy in accordance with all payer-specific coding rules. The audit will also compare the distribution of claims based on CPT code to other national average dollar-billed amounts for the same specialty to highlight risk in both areas.
A HIPAA compliance audit for medical billing that ensures that you are compliant with federal, state, and payer-specific billing rules. The audit also reviews the applicable submission requirements for all claims submitted to CMS, including the OIG Work Plan's annual risk areas and any relevant Anti-Kickback Statute requirements, and each provider's signed payer contracts regarding timely filing windows and prior authorization requirements, which can vary by plan.
Checks clinical documentation for all the required billing codes as described by our payers — determines if the clinical documentation supports the medical necessity of a service, meets the timely filing requirements of the payers, has the correct provider signature, and whether all MAC LCD regulations have been met. The most common findings in the RAC and CERT reviews are gaps in documentation.
Analysis of denied and rejected claims, the payer uses claim patterns at the ANSI claim level and classifies by CO Code, PR Code, and OA Code. Claim patterns are analyzed by payer, provider, and CPT Code classification and used to identify the top claim denial reasons contributing to the First Pass Denial Rate, and show the claim pattern to a specific point in the billing process, not just as a separate submission error. See our dedicated denial management services for ongoing resolution support.
Systematic bucket analysis of 30-day, 60-day, 90-day, and 120-day-plus aged receivables, with an identifiable recovery amount determined for each bucket. Recoveries are created by separating out claims that are able to be recovered from claims that fall outside the timely filing limit, state statutes, or have unresolvable CO-45 payment adjustments included in the reported accounts receivable total that do not result in collectible revenue.
Benchmarking actual reimbursement per CPT code with each payer’s contracted fee schedule is essentially a payment integrity review that identifies systematic underpayments prior to closing them off as adjustments. Medicare reviews for compliance with MAC local coverage determinations, compliance with NCCI edits, billing rules for Medicare Advantage, and RADV audit readiness in value-based care arrangements.
This audit identifies missing charges by comparing procedure volumes documented in clinical or scheduled records vs. claims submitted. This means that any volume gap would be revenue that never made it to the AR. On the payment side, the review of the 835 remittance postings at a transaction level is to identify ERA mismatches, discrepancies in the PLB segment, and payment posting errors that either artificially inflate patient balance or cause underpayments to be hidden.
A prospective billing audit involves reviewing claims prior to submission, particularly for new services on board, a new coding staff, or in response to a payer notice. Using a retrospective billing audit, claims that were previously adjudicated over a prior six to twelve months would be reviewed to develop a baseline and assess recoverable revenue from the providers.
The 5-step process for all Medical Billing Audits will incorporate a credentialed CPMA Auditor who will exercise professional judgment at each of the 5 phases of the audit, regardless of whether it's during the discovery call or in the summary audit report.
This includes gathering information, including claim volume, specialty, payer mix, and purpose of audit - deny claims, recover revenue, or verify documentation compliance, to define the deliverables in writing to all parties involved.
BAA is the initial step before any data transfer begins. Each audit participant's data will be transmitted via SFTP or via the HIPAA-compliant portal when configuring their EHR system.
Conducting the audit will include the use of CPC/CPMA credentialed auditors applying the OIG statistical sampling methodology (random/stratified selection) for auditing for coding accuracy, documentation integrity, and billing compliance.
The results of each audit are provided in written format and segregated by CPT code, provider, and payer. This includes the overall error rate for each audit, as well as the dollar amount of revenue that the audit participant will be able to recover.Â
A defined corrective action plan is provided by our auditor to each audit participant at the conclusion of the audit. The auditor is available to assist with the implementation of the corrective actions.Â
Timeline: Most audits are completed in 7–30 days, depending on scope and claim volume.
When practices outsource medical billing audit work to a CPMA-credentialed team, it allows you access to experienced auditors with little to no familiarity with your processes or procedures. An in-house audit team can become so accustomed to working within the same environment that they develop blind spots when reviewing their own work. External healthcare billing audit services let you identify any coding drift patterns and/or documentation issues that may have been acceptable as a normal over time.
A 97% collection rate and 98% first-pass accuracy, and through 250+ client practices, this type of audit-to-corrective-action process enables a decrease in denial rates, on average, by 40%+ within two billing cycles from implementation.
When practices implement the findings from an audit within 30 days, there will generally be an 8–12-day reduction in accounts receivable days in the following quarter — an improvement in cash flow without having to add billing personnel.
The independent review requirement of the OIG Seven Elements will be satisfied through completion of an external audit, which provides documentation that an internal review can never do, regardless of how deep an internal review goes.
Orthopedic auditors understand global periods and multiple procedure reductions for billing all the claims associated with an orthopedic audit. Similarly, cardiology claims will be audited by auditors who understand both interventional modifier logic as well as the bundling rules associated with cardiology claims.
Billing will continue to submit their claims regularly throughout the duration of the entire audit. There will be no interruption of cash flow or freezing of billing during the audit.
Each audit report will include a revenue recoverable estimate associated with each finding category — as opposed to general observations that revenues should be increased, there will be a dollar amount attached to the specific coding or posting error.
In those instances where the auditor finds a gap in the coder's workflow, the corrective action plan will also include education targeted at specific skill deficits and/or knowledge deficits the coder had in relation to the identified error.
Each specialty uses different sets of CPT codes, modifiers, and payer LCDs. Physician billing audit services are performed by specialty, thereby assuring that each audit will be assigned to an auditor who has been trained with experience performing audits specific to the billing logic used by the respective specialty.Â
The fees for medical billing audit service vary based on claim volume, specialty complexity, and the scope of the audit. The engagement model structure and how it helps relieve the anxiety of "sticker shock" before it becomes a reason not to engage in discussion.
A free audit of 25 to 50 of your highest billing codes would be provided to you to perform a complimentary audit of claims. Immediate findings would be determined, and a full engagement would be outlined using this data. There would be no obligation beyond the free audit.
Audit pricing is based on claim volume and the complexity of each specialty. For just one practitioner, a single-location audit would differ in terms of price and complexity from an audit of a multi-site group.
In regard to aged balance receivable work, audit pricing is based on a percentage of dollars actually recovered from accounts receivable more than 90 days old. If no dollar amounts are recovered, no fee will be charged.Â
