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The Transformative Power of Medical Billing Audits

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A medical billing audit is akin to a safety check. When a government or private payer denies some claims or has not decided, they want to verify if the medical records substantiate the claims. This might prompt concerns about whether your records adhere to the rules set by Medicare or insurance companies. You might even recall when your billing manager proposed a review of your billing process.

Medical Billing Audit is not just about playing defense

It is about going on the offense, too. Taking the time to do a medical billing audit is bright, regardless of your reasons. But it is not just about ensuring everything’s in order; it’s also a chance to boost your practice’s profits, especially if you get creative. While many doctors might only think of an audit as checking clinical records against billing codes, there’s more to it. Sure, that’s crucial; medical billing companies in the USA use this tool to highlight the anomalies and take healthy measures to prevent revenue loss. 

The Simple Way to Check Your Bills

Let’s say you are looking at your medical bills to see if everything adds up. A close look might reveal that some things you did for a patient were not charged. Or, your records show that your services were more extensive than what was billed for. Also, you may be missing essential details in your records, like quality measures.

These days, Medicare pays more attention to quality. You might face penalties if you need to keep track of specific quality measures in your records. But if you do a good job, you could even get some extra money as a reward. A medical billing audit can help you find simple ways to improve and get those bonuses.

Keen Observation of Billing Audit

The “micro” way of checking medical bills often means giving more training to doctors and staff. Medical billing audits also help fix any incomplete procedures the staff might have. Doctors and healthcare workers also get training on improving their notes and using the correct codes. This can improve patient care and medical records. It might also mean getting more money for the services given and even extra payments as rewards.

Now, if this is the small-scale way, what is the big-scale way to do a medical billing audit?

Assessment of Charge Capture

Even before patients come to your office or hospital, you can affect your income by deciding how much to charge for your services. Most doctors charge a specific amount based on a standard fee schedule.

You can easily find this fee schedule for doctors who accept Medicare in your area. If you set your prices at two or three times the Medicare fee schedule, you’ll probably never get paid less than what any insurance company will cover for your services.

Some doctor’s offices set their billing systems to charge Medicare exactly what Medicare allows for each service. This means the patient would not owe anything after Medicare and other insurance pay.

 However, if you use this method, you must update your billing system yearly because Medicare’s fees change. If you do not, Medicare might only pay what’s on their fee schedule, even if you charged more.

Rejections and Notices Before Getting Services

Track your denials carefully! Pay attention to why claims are denied and use that information to improve how you document medical procedures. Better documentation, like ensuring the diagnosis matches the procedure, can help avoid denials because of missing information.

Sometimes, denials happen because Medicare only covers certain procedures several times or for specific diagnoses. In these cases, you can ask the patient to sign a paper called an Advance Beneficiary Notice. This lets them know they might have to pay if Medicare denies the claim. Explaining this to patients can be a hassle, but good management and electronic health record systems can make it easier and more understandable for them.

An audit serves as a planning tool. 

A macro approach to medical billing audits can help you plan how to run your practice better. You might see opportunities to hire more clinical staff, like nurse practitioners or physician assistants. These skilled professionals can boost your practice’s profits by seeing more patients without increasing costs.


For many doctors, taking care of patients is the main focus of their job. However, they must also manage the business well to have a successful practice. Medical billing audits help with both parts of the job—running the practice smoothly and serving patients better. Whether it’s an audit done within the practice or by an external party, it’s essential to make things work well.

To sum it up, let’s quickly go over what medical billing audits include and offer. We will look at each type of audit separately so it’s clearer.p


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