Audit Risk Management
Coding and Billing Regulatory Risks
The OIG lists the following items as specific regulatory risks most frequently subject to audit:
» Billing for items or services not rendered
» Submitting claims for supplies and services that are not reasonable and necessary
» Double billing
» Billing for non-covered services
» Failure to properly use coding modifiers
» "Clustering" (using only a few codes on the theory that it will average out)
» Billing for services provided by unqualified or unlicensed clinical personnel
» "Upcoding" (using a higher reimbursement code than the code reflecting the service rendered)
» Inappropriate balance billing
» Routine waiver of co-payments and billing third-party insurance only
» Discounts and professional courtesy
» Improper billing for incident-to services
» Improper reassignment of physician billing numbers
» Failure to refund credit balances due to patients and payers
How does (B)n help practice's manage audit risks?
Integrated EHR (Electronic Health Record): (B)n’s Integrated EHR solutions assist practices in their overall compliance and audit management strategies. Complete, consistent and legible documentation support proper E&M coding, and reduce audit risk.
Audit Exposure Monitoring: Automated and comprehensive rule-based tests encourage optimum coding practices and minimize audit exposure, post-payment refunds and penalties due to over-coding.
Post-Payment Audit Risk and Compliance Management: (optional) Continuous audit pattern monitoring, warning generation to workbench, and monthly review by compliance consultants for possible audit exposure.