A medical practice needs chart auditing to beat federal payer audits. These audits ensure the accuracy of medical chart documentation while describing medical services provided. Successful auditing confirms that your charts meet billing and coding standards. It also guarantees maximum return on revenue collections. Below is a guide on all you should know about chart audits in a medical practice.
Auditing principles and standards
- Integrity of auditors
- Professional objectivity in collecting, evaluating and sharing information
- Respect for the value and ownership of information.
- Nondisclosure of information without appropriate authorization
- Applying expertise, experience, and acumen to perform audits
Benefits of chart auditing in health care
Determining requirements
Determining requirements
Managing a healthcare practice requires the use of The Health Plan Employer Data and Information Set for setting performance measures. Health plans have to report multiple set measures annually. This allows staff and potential members to evaluate plans after understanding your quality of care. This is also possible with medical chart auditing and process specific audits.
Measure for quality improvement
It is a great idea to contact one of the top medical billing companies near me for comprehensive chart auditing. This allows evaluating adherence to industry policies. Additionally, it assesses compliance with regulatory methods and procedures in health care. Chart audits come in handy to check your quality of care and to determine where it needs improving. This is possible through quality initiatives to enhance outcomes, processes, and system efficacy.
Strategic initiative
Undertaking internal chart auditing is a crucial role in healthcare practices. You have to ensure that all health records match the services level in the medical record. Accurate and comprehensive documentation of medical records allows delivering quality care in a medical practice. Undertaking comprehensive char auditing is the best way to enhance documentation and finances in your organization. The audits determine airs for improvement and correction.
Streamlining basic functions
Chart audits in a medical practice have a significant impact on care delivery efficiency while streamlining basic functions. The audits document diagnosis codes and procedures matching your documentation. On revealing inaccurate areas requiring corrections, you get a foundation to ensure future documentation training and monitoring.
Chart audits in a medical practice have a significant impact on care delivery efficiency while streamlining basic functions. The audits document diagnosis codes and procedures matching your documentation. On revealing inaccurate areas requiring corrections, you get a foundation to ensure future documentation training and monitoring.
Compliance
Your medical practice requires a monitoring and auditing process for your medical records. This addresses compliance with applicable industry rules and regulations. Your practice avoids resultant problems from non-compliance including fines and lawsuits. Every medical practice has a responsibility to determine the legitimacy of its activities.
The compliance risk checklist includes:
- Abnormal activity patterns
- Routine coding and auditing
- Routine monitoring of documentation
- Auditing access and documentation of electronic health records
- Monitoring assigned codes to match coding system guidelines
- Auto-generation of warning messages during unauthorized access
Audit trails
These highlight the auditor’s name, the purpose for the audit, workstation, and particular document. Additionally, an audit trail describes the audit event including date and time. It also captures any corrected data in the medical records to give auditors where to begin when undertaking compliance audits. The audit trail is electronic for the efficient utilization of health records. This allows the generation of reports for use by compliance personnel.
Administrative requirements
Validation of medical records is among the rules and regulations of federal law. Auditing charges coded and billed is a mandatory requirement by medical offices. Comprehensive medical chart audits also measure compliance while limiting the chances of fraud and false information. Getting this right requires strategies including:
- Fraud prevention awareness
- Investing in systems able to limit fraudulent activity
- Having standards for managing electronic health records
- Implementation of fraud prevention policies, procedures, and systems
Fraud prevention training and awareness
Your medical practice needs awareness programs to identify process regarding handling electronic health records for stakeholders to follow. Have training programs focusing on potential fraud risk areas. This education should focus on ongoing training. Regular scheduled training allows all users to get current knowledge regarding the appropriate handling of medical documentation. The training should include reviewing organizational procedures and policies.
Additionally, your training program should address the course of action in case of false records, security breaches, and gross violations. You have to ensure that your medical office follows the Health Insurance Portability and Accountability Act. This relates to sharing and handling patients’ medical details according to meet security rules and regulations.
Reasons to trigger medical record audits include:
- Regular complaints from patients for wrong billing
- Improving staff efficiency
- Verifying data for claims processing
- Checking for wrong codes
In a nutshell
Accurate and detailed medical records are essential in medical practice. Comprehensive chart auditing enhances safety, service care delivery, and financial returns. Professional auditing defines the criteria for quality medical records through eliminating errors. Chart auditors evaluate the date to check for missing elements and to confirm authenticity.
