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What’s the Difference Between an Audit and a Review?

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So you’ve selected which type of internal audit/review you’re going to conduct for your practice.  Now you need to determine if you’re going to do an audit or a review.  What is the difference you may ask?

Audit

An audit is conducted after claims have been submitted to a payor.  The advantages are that a claim has gone through the entire process, and the analysis can include how the payor adjudicated the claim.  It allows for a complete picture of the results of the service delivered by the provider.  This will let you know which services a payor:

·        bundles or unbundles

·        up or down codes

·        pays, and how much

·        denies, and for what reason

A primary disadvantage to performing a claims audit is that if problems are discovered, they have already been submitted to the payor so you may need to:

·        submit voids or adjustments to correct billing errors

·        self-report compliance errors

Review

A review is performed before any claims are submitted to the payor.  It allows for the discussion and research of any issues that arise, and the capture of any additional supporting documentation that may not have been included in the initial submission.  Of course, care must be taken to ensure documentation is not improperly supplemented.  Provider notes may not be altered, studies that were not reviewed by the provider at the time of service are not admissible, etc.

Performing a review enables you to make any coding or billing corrections prior to submitting claims, avoiding the need to submit claim corrections.

A review also offers the practice an opportunity to discuss any issues identified to determine the course of action to take.  This is particularly important when documentation deficiencies deem a service unbillable, or when a compliance issue is identified.

A disadvantage of performing a review instead of an audit is that you don’t have a full picture of the impact of the service provided on the practice.  Without seeing how the payor adjudicates the claim, valuable insights into the bottomline net results are missed.

 

Which type of process makes the most sense for your practice?  Weigh the pros and cons of each, and give us a call

If you’ve got any questions or need help selecting a chart review method.  Contact us at sue@habaneroinc.com. 

ICD-10 Transition: Y2K will look like a child’s game

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ICD-10 will impact every area of your medical practice or billing company!

There have been so many changes put upon medical practices in recent years, from EMR, new HIPAA and HITECH privacy and security requirements, advances in medical care, payor audits, just to name a few.  You may not have appreciated just how big the transition to ICD-10 is.

Everyone covered by HIPAA must transition to ICD-10.  Your participation is not optional!

You may be thinking that codes change every year, so why is the transition to ICD-10 such a big deal?  ICD-10 codes are different from ICD-9 codes and have a completely different structure. Currently, ICD-9 codes are mostly numeric and have 3 to 5 digits. ICD-10 codes are alphanumeric and contain 3 to 7 characters. ICD-10 is more robust and descriptive and there is not a one-to-one crosswalk from ICD-9.

ICD-9 is 30 years old, it has outdated and obsolete terms, and is inconsistent with current medical practices.  It’s time for a change, and the sooner you begin, the more time you’ll have to get it right.

Habanero, Inc. has been consulting to the healthcare industry since 1996 and is poised to help your medical practice or billing company prepare for, and transition to, ICD-10.  We offer affordable training classes and consulting services.