Medical Billing Audit

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Physicians work hard and concentrate on providing the best possible care to their patients. In order to be able to continue doing so, it is essential for their billers (in-house or outsourced) to perform a thorough job with their revenue cycle.

Providers often have a very busy schedule and are unable to allocate the time necessary to dig deep into the billing portion of their practice. However, if physicians are unable keep a close watch on their billing practices, they will eventually find themselves in dire situations and potentially at risk for an audit.

The purpose of a medical billing audit is to present a bird’s eye view to the physician, as to where his/her practice stands as far as revenue cycle management is concerned. The audit process entails a thorough analysis of the practice to identify the gaps in the overall billing process, find problematic areas, deficiencies in charge pathways, issues in accounts receivable and coding etc.


Usually physicians know what is coming to their bank but they do not know what they are missing. They only get AR reports but do not get a chance to know about the exact issues their practice is facing. An audit can help them get upfront to all the existing issues, the recommendations can enhance the performance level and physician can exactly know about his practice.


Once we sign in for an audit, we follow the below procedure:

  • Run Reports

Accounts receivable, scheduler, patient balances and insurance payment reports are run to get an overall perspective of the practice.

  • Compile Sample Data

After running all the reports, we extract data for a certain time period, certain claims & certain accounts. This data is then thoroughly analyzed to identify issues.

  • Follow Up on Claims:

Once sample data is compiled we contact insurances and verify status of each and every pending claim. All findings are properly noted against each claim with suggestions for corrective action.

  • Payer Enrollment Status

Provider’s participation/enrollment status verification is extremely important as it is the base on which the provider is reimbursed. We check and verify if provider is properly enrolled with all the payers.

  • Paid Claims Fee Schedule Check

Usually charges for fee schedule are added at the time of setting up the practice management software. Incorrect setup may result in claims being under or over paid. If they are under paid then it is a loss for the physician and in case claims are overpaid; physician’s practice can come under a CMS audit which may take up to 2 years to complete and a hold on payments during this while.

  • Practice Management Software Configuration:

It is imperative that PM software is configured and tuned for maximum efficiency. We check and verify that software is setup correctly, optimized and utilized for efficient billing practices.

Analysis Summary

Once all above mentioned audit procedures are complete, we prepare an analysis summary which contains audit highlights, list of issues and its effect on the practice e.g. how many claims were not on file, how many lost filing limit, what percentage is paid, denied or has resulted as a loss etc. We also suggest corrective measure with each identified problem.

The summary contains facts, figures and charts representing the practice condition.

Detailed Report:

The detailed report contains the audit trail of the sample data. All the working done on each and every claim, response from insurance representatives, findings and issues with claims.