Medical Auditing

Medical auditing is an assessment of performance in a healthcare organization.

It is an important component within healthcare organizations, as it prevents liability and improves the performance of the organization. Conducted by a medical auditor, the medical audit is critical to the compliance plan of a healthcare organization.

Medical audits are a necessity in:

  • Analyzing the policies of the organization for effectiveness.
  • Improving revenue management and collection.
  • Educating providers and staff of current guidelines.
  • Avoiding audits, litigation, and plan denials.
  • Improving the quality of patient care.
  • Minimizing coding and billing errors.

Medical auditing resolves ignorance, and ignorance is a liability. Documentation mistakes are a far too common occurrence within medical settings, so it is important to ensure accuracy in coding, policies, and procedures in the organization.

The law does not require intent and does not allow for errors to that degree. Errors in coding and billing that result in higher reimbursement will look like fraud, whether it is deliberate or by habitual error. Additionally, when brought to light, documentation errors often lead to negative consequences for the organization, such as loss of accreditation, and even the physician’s licenses.

The Office of the Inspector General states “If you knew OR SHOULD HAVE KNOWN the submitted claim was false, then the attempt to collect payment constitutes a violation”.

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SHOULD HAVE KNOWN is the key phrase.

This means the provider is accountable. They are accountable by law for upcoming, double-billing, unbundling, failing to establish medical necessity or any other errors that would result in money paid that was not earned.

In general, the consequence of such errors results in claims not being reimbursed by the insurance company and claims that are ultimately rejected or denied. However, penalties for erroneous billing and auditing can be more costly and severe. Penalties for violations can include up to three times the programs’ loss as well as fines up to $23,331 for each claim submitted in violation of the law. Attempting to defraud the government can also lead to imprisonment.

At J3 Revenue Cycle Management, we understand the importance of efficiency within medical organizations. We are committed to providing comprehensive services for medical auditing in Fort Lauderdale. Call (954)544-2706 to learn more.