Usually, before any payment of a claim is done, the claim undergoes a thorough auditing process to analyze the reasons why the company should or should not pay the claim. That is, a rigorous examination process is undertaken to establish if the claim meets all the necessary legal requirements and the amount payable (Office of the New York State Comptroller, 2013). On the whole, the claim should present sufficient details so that the audit team posses enough information to make a sound conclusion. Therefore, this paper presents nine steps that the audit team(s) should follow when auditing claims.
Firstly, identify a precise method for defining errors. This is helpful in evading differences that may arise when interpreting ambiguous coding, documentation rules, and billing.
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Secondly, establish a sampling technique. Specifically, determine whether to use audit prospective or retrospective techniques. Prospective auditing enables one to determine and correct documentation and coding errors before billing is done. On the other hand, retrospective billing enables one to identify if the Fiscal Intermediary (FI) or the claim was accurately paid by the carrier and evaluate the basis for denials (HCPro, 2005).
Thirdly, establish the period for sampling. Deciding the period to sample is necessary. It does not incline one to a specific period. Rather any time, week, month, fiscal year, will be sufficient as long as one sticks to it during auditing. Fourthly, decide the number of claim packages for analysis. One can incline towards the use of a random sample or statistical sample as long as the sample represents the whole population. For instance, healthcare institution can be able to determine accurate picture by using twenty-five claim packages while a physician can get sufficient information by using ten claims. Additionally, either case of the sample to be analyzed in healthcare institutions should include the payers such as Medicare and Medicaid (HCPro, 2005).
Fifthly, determine the data sources to be used. In a medical setup, acquire claim forms after determining the sample to use and obtain the necessary medical records. The records are divided into three major constituents; clinical, financial, and policy related records for easy evaluation of findings. Sixthly, evaluation of documentation and assessment of findings is conducted. Here, the accuracy of billing and record documentation is evaluated with the guidance of predetermined policies and procedures to determine if the documentation is inadequate or contains errors (HCPro, 2005). Additionally, coding errors are determined at this step.
Furthermore, a “reverse” audit is performed on high-risk areas. For instance, a “reverse” audit is conducted in a laboratory to whether the physician orders were correctly billed and coded. Moreover, quantify the findings by any use of either spreadsheet or any database that has elements one would like to verify indicated at the top. The elements can be account number, admission date, and designated control number among others. However, the patient's name should be exempted. The last step is to calculate the payment errors. It is essential if one uncovers a discrepancy, he or she should determine the cause of the error, correct it and evaluate whether the correction worked. If it affects billing, notify the FI or carrier the method used to uncover it and how it was corrected. Finally, take the necessary steps to initiate payback.
Overall, claims auditing process is essential to determine the violated claims, those bypassed and other necessary internal control. The criteria build more confidence amongst concerned parties and therefore enhancing the management of the working environment of the company.
References
HCPro, I. (2005). Audit, analyze claims with nine steps - www.hcpro.com. Retrieved from http://www.hcpro.com/HIM-46030-865/Audit-analyze-claims-with-nine-steps.html
Office of the New York State Comptroller. (2013). LOCAL GOVERNMENT MANAGEMENT GUIDE-Improving the Effectiveness of Your Claims Auditing Process (pp. 5-8). New York: Division of Local Government and School Accountability.
