Auditing for Reimbursement

Why This Topic Matters

Understanding audit findings can help a practice spot recurring payment problems, improve claim accuracy, and better align billing workflows with payer requirements and contract terms.

Article Sections

1. Claims audits and sampling approach

   Introduces the purpose of claims audits and describes general approaches for selecting audit samples. It also distinguishes between forward-looking and after-the-fact audit review.

2. Sample selection and payer timing considerations

   Discusses what should be represented in the audit sample and emphasizes payer-specific submission timing requirements. It also addresses the importance of identifying timing-related denials.

3. Common causes of denials

   Reviews broad categories of claim denial causes, including patient information problems, payer coordination issues, coverage limitations, and authorization-related concerns.

4. Coding updates and modifier use

   Explains that coding sets and related guidance change over time and highlights the need to stay current with annual updates. It also discusses the general role of modifiers in claim processing.

5. Payment reconciliation and contract review

   Covers matching payments to fee schedules, patient responsibility amounts, and account adjustments against supporting documentation. It also notes the importance of contracts in reimbursement review.

6. Tracking denials and reimbursement management

   Describes the value of monitoring denial patterns over time and using summary tracking to identify payer behavior. It closes with broader reimbursement management considerations for a practice.