Protect Your Practice: The Importance of Internal Audits in Fertility Billing

In the highly regulated healthcare industry, you must implement an internal audit process; as it is quite paramount for the success of your fertility billing. Whether you run a solo practice, or a large fertility center, audits enable you to identify the noncompliance and missed revenue.

Moreover, accurate coding and documentation always enable you to receive maximized reimbursements from insurance companies and this is exactly running routine internal audits plays a vital role.

By doing an internal billing audit, you will be able to identify errors, avoid claim denials, and reduce lost revenue or payer issues. You can have a team member or a specialized billing company handles the audit to ensure everything is running smoothly.

Now, it is important to know what internal audit in fertility billing solution is.

What is internal audit for fertility billing?

The primary objective of an internal audit is to ensure that your fertility clinic billing are accurate and efficient. Think of it as having a second pair of eyes to review your billing and coding processes. A fertility center billing audit helps protect your practice from fraudulent billing and claims, which can result in big Medicare penalties. It also helps you spot and fix any issues that could bring unwanted attention from a Recovery Audit Contractor (RAC).

A fertility billing audit, or revenue cycle management (RCM) audit, looks at more than just coding accuracy. The purpose of an audit check is to ensure that the diagnostic and procedure codes are accurate but on the other hand, RCM audit always digs deeper down the line.

An internal audit review process checks all the critical parameters of you billing cycle that includes patient registration, verifying insurance eligibility, and collecting copays and deductibles.

A systematic fertility clinic billing audit process requires your internal audit team to thoroughly check the entire health record of your practice to ensure everything is accurate and in proper order.

In fact, the audit process carefully reviews your clinical documentation to ensure that you have properly justified the services you have billed for. It reviews the following the things-

• Mistakes in provider documentation
• Errors in ICD-10, CPT, and HCPCS codes, including incorrect use of modifiers and how often these mistakes occur
• Issues with undercoding, upcoding, and modifier usage
• Submitting duplicate claims
• Unbundling services inappropriately and other billing practices that could be seen as fraudulent, intentional or not
• Lack of proof for medical necessity
• Problems with patient insurance eligibility
• Reimbursement issues with payers
• Non-compliance with payer rules and guidelines

A robust internal audit program allows you to improve your overall documentation process, mitigate billing and coding errors, ensure that these errors are never repeated and optimize the end-to-end process workflow.

Let’s check about the vulnerable areas in your billing process that requires internal audit process-

Upcoding happens when you submit a claim using a higher or more complex code than what’s actually supported by the documentation or the patient’s condition. For instance, if your documentation supports a level three Evaluation and Management (E/M) service but you code it as level five, it inflates the claim and leads to incorrect billing.

Audits can also uncover down coded or denied services. This happens when the payer decides to pay for a lower level of service than what you billed. When services are denied or down coded, the audit will check the reason by comparing what was billed to what was paid.

Audits can help you spot under documented services. These are cases where the care you provided could justify a higher E/M level or extra services, but the documentation doesn’t fully capture it. This results in lost revenue for your practice.

Audits can uncover underbilled services, another common cause of lost revenue. By comparing your chart notes to the billed codes, audits help spot both underbilled and overbilled services.

Using modifiers can be tricky, especially in fertility billing solutions. For instance, modifier 25 is used to show that a separate and significant E/M service was provided on the same day as a procedure. In fact, there are many areas to focus on for internal audits to ensure everything is running smoothly.

You should also look at common payer denials and new medical services. Pay close attention to data like misapplied codes, incorrect code sequences, and missed codes, as these can lead to undercoding or other issues.

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How do fertility billing solutions work?

You can be better prepared if you know how the audit process works. Always remember one thing that is no one size that fits all method when the audit is concerned. However, there are few steps that enable you to implement a perfect internal audit process and these steps include:

1) Decide the scope of audit:

You have a few options for audits:

1. Random Audit: This involves picking claims at random, regardless of their size.
2. Comprehensive Audit: This type looks closely at all the claims to focus on finding and claiming refunds.
3. Hybrid Audit: This combines both random and comprehensive approaches. It evaluates samples from all types of claims to find any issues.

When deciding on the audit type and how many claims to review, make sure you have the right resources and support to carry it out effectively.

2) Set up a timeline for audit:

Choose the number of claims to review based on how many doctors are in your practice. Also, decide the time frame for pulling these claims—whether it’s a week, a month, a quarter, or a whole year.

3) Identify the vulnerable areas:

Next, look at your fertility billing reports to spot any risks or worrying trends. Compare these reports with past performances, whether monthly or yearly. Check how your providers and billing staff use CPT codes to make sure they’re coding patient encounters correctly. See if their coding patterns match industry averages. A medical billing audit uses benchmarking to do this. Examining these reports will help you see if patient encounters are coded right and if billing practices are correct. Track your data using spreadsheet software and organize your findings into a report.

Outsourcing your fertility billing to Sunknowledge brings many benefits. Our audit-proof billing process helps you stay compliant and maximize revenue. Whether you’re running a solo practice or a large center, regular internal audits are key to catching errors and missed revenue.

Sunknowledge isn’t just a medical billing service; we act as a seamless part of your team, working in your time zone. We ensure accurate medical billing, reduce errors, and prevent claim denials.

With Sunknowledge, you get a dedicated team focused on your success, so you can concentrate on patient care.