Compliance: Cut Audit Odds With This Expert Advice

Why This Topic Matters

Understanding audit trends and internal review processes can help practices strengthen compliance programs and identify documentation or billing risks before they become payer issues.

Article Sections

1. Audit environment and payer review trends

   This section introduces the broader audit climate and summarizes how payers are approaching claim review. It also frames the discussion around compliance concerns affecting medical practices.

2. Private payer audit activity

   This section discusses the prevalence of private payer audits and the use of analytics to identify claims for review. It focuses on general audit activity rather than specialty-specific coding guidance.

3. Common claim issues under review

   This section outlines broad categories of claim problems that can attract scrutiny, including errors, waste, abuse, and fraud. It describes these as general areas of audit attention.

4. Review categories for coding and billing

   This section covers major claim profiling categories used in auditing, including evaluation and management, procedure utilization, modifier use, and time-based review. It also references oversight from federal compliance organizations.

5. Modifiers under review

   This section describes payer attention to modifier usage and notes that audit focus may extend beyond commonly reviewed items. It discusses how modifier-related review issues can surface in payer programs.

6. Automated reviews and audit triggers

   This section explains the general sequence of automated claim review followed by human review. It also references payer monitoring resources and public audit reporting sources.

7. Internal audit planning

   This section explains why practices are expected to maintain an internal audit plan and how such a plan fits into a compliance program. It focuses on general planning and documentation structure.

8. Risk-based auditing methods

   This section introduces risk-based auditing as a way to prioritize internal review activities. It discusses comparing practice activity with broader peer data and using predictive approaches.

9. Chart review sample sizing

   This section addresses how practices may decide how many records to review based on risk considerations. It covers general sampling approaches and audit selection concepts.

10. Measuring results and follow-up

    This section covers post-audit measurement, including tracking outcomes and scheduling re-reviews. It also discusses using audit results to guide education and remediation efforts.