How to Do an Audit on Medical Claims

Auditing medical claims for any healthcare facility requires insurance billing experience

Providing an audit on medical claims to any healthcare facility requires a certain amount of knowledge and experience with "International Classification of Diseases" codes or ICD coding and "Current Procedural Terminology" or CPT coding. An auditor should also have a general knowledge of medical terminology and medical bundling of procedures, which means that more than one procedure is connected to a CPT code.

Things You'll Need

• ICD-9 or ICD-10 book for current year
• CPT book for current year
• Medical charts

Instructions

1. Make sure you have a firm knowledge of current CPT coding and ICD-9 coding, as well as a good understanding of medical terminology. To do a good audit on medical claims for any healthcare facility it is best that you are auditing claims that you have no connection with, so that the audit is unbiased.

2. Take a cross section of medical claims from the facility or pull the medical claims from a certain time span, such as the last three months. It will be necessary to cross match the claims with the medical charts to get a good understanding of the procedures that were done and match them to the procedures that were billed.

3. Make sure that all the procedures and billing match up correctly and that there is documentation of any billed procedure in the chart. Medical fraud occurs when procedures are billed that cannot be substantiated with documentation. In the medical field, if it was not documented, it was not done, and audits for any healthcare facility should reflect any errors found.

Tips & Warnings

• Cross-checking other claims with similar procedures is a good way to tell if this is really a case of billing fraud or purely a case of medical billing charges billed in error.

• Always substantiate any audit errors you find. Make sure that you can show not only where the errors are but also how the mistakes could have been avoided.

References

• Employer's Guide to Health Care Cost Containment
• Medical Audits
• Preparing for Medical CMS Audit