Medical Billing process - Claims Audit

Charge Auditing process

This process is not followed in every company but still its a good method to track and make sure the quality of the billing.

Audit Department’s primary function is to see that there should not be any error in the Claims sent to Insurance Companies and they have to ensure that all the quality checks are correctly performed in the Company.

Basically Audit person should be experienced in data entry process of Patient Demographic and Charges and should have thorough knowledge on Billing Rules and Regulations of Charges. After receiving files from Charges department, details should be updated in the Excel Spread Sheet.

While checking Patient Demographic, audit person carefully check Name, address, SSN, DOB, H Ph, W Ph, Policy ID, Coverage details, Subscriber Details, Employer details, etc.

While checking Charges, audit person carefully check DOS, Procedure Code, Diagnosis Code, Modifier, Units, Value, TOS, POS, Ins Number, Doctor Number, Location, Prior Authorization, Referral, etc..

They should check each and every field of patient demographic entry and charges entry before submitting the claims for transmission.

If any error is found in the data or any data not entered in the system should be informed to the Charges department through mail or some other way for correction and the same information should be updated in the Excel Sheet for record purpose.

After corrections are over , audit department has to check again and approve the claims for transmission.

Errors done by the entry persons should be noted down and mail sent to their department managers stating the errors. If the entry persons do errors regularly then warning messages to be issued to entry person to avoid unnecessary errors in the entry part.

After auditing Patient Demographics and Charges Files, information like Entered by Whom, Entered date, # of charges, # of patients, correction details, audited by person ( name), audited date should be updated in the Excel spread sheet.

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