Outpatient Surgery Magazine, providing current information on Surgical Services, Surgical Facility Administration, Outpatient Surgery News and Trends, OR Excellence and more.
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Do you want it to be an annual benchmark to indicate your overall coding accuracy, or do you want to hold audits whenever you see an uptick in denials? Once you set your goal, you can better tailor the rest of the audit to finding and implementing a solution for any billing issues. Choose the type of review There are 2 different styles of claims audits: random or focused. The former will be a general sample of your practice, whereas the lat- ter is a sample from a pre-defined challenged area, like claims from a specific physician, specialty or payer. For example, you may want to hold annual internal audits to get a benchmark of your overall coding accuracy. For this, you'd conduct a random audit, choosing a selection of claims at random from different physicians, payers and specialties. But after conducting this random audit, let's say you see that there are consistent issues with your total joint claims. You can then hold a focused audit where you take a sam- pling of only total joint claims and check those against your current payer policies and contracts. Once you find the problem in that focused audit, you can then adopt corrective measures. Understand the scope of the audit Consider whether you need a retrospective or prospective audit for claims submission. In a retrospective audit, you review accounts and reports after you've submitted the claims and received reimburse- ment from the insurance carrier. In a prospective audit, you review the accounts before submitting the claims. When most people think of audits, they think of retrospective ones. But prospective audits can be helpful if your coders have trouble sub- mitting claims from a particular physician or service. These prospec- 3 2 O C T O B E R 2 0 1 6 • O U T PA T I E N TS U R G E R Y. N E T • 4 5