Compliance: Have You Built an Audit Plan? Payers Are Expecting It

Why This Topic Matters

Payers are increasingly using data-driven methods to identify claims for review, so practices need a structured audit approach to reduce compliance risk and respond to audit expectations.

Article Sections

1. Private Payer Audits and Predictive Analytics

   Introduces the broader audit environment and how analytics are being used to identify claims for review. Covers the role of private payer auditing and the general shift toward predictive methods.

2. Top Issues Payers Examine

   Summarizes the major categories of claim concerns that may draw attention during payer analysis. Discusses broad problem types seen in coding and billing review.

3. Review Categories in Medical Practices

   Describes the main claim profiling categories used in auditing, including service utilization patterns and time-related review concepts. Focuses on how claims may be grouped for analysis.

4. Modifiers Under the Microscope

   Explains that modifier use is a common review area and that scrutiny may extend beyond the most familiar items. Notes that payer and program review activity may include modifier utilization.

5. Automated Reviews Are the First Step

   Outlines the general sequence of automated screening followed by human review. Mentions sources practices can monitor to stay aware of current audit focus areas.

6. Payers Expect You to Build an Audit Plan

   Discusses the need for an internal audit plan and how it fits into compliance efforts. Emphasizes structured self-review as part of a practice program.

7. Understand Risk-Based Auditing

   Introduces risk-based audit planning and the use of comparative analysis across services and specialties. Focuses on how practices can prioritize areas for review.

8. Base Number of Chart Reviews on Risk

   Covers chart review sizing based on perceived risk and when additional review may be warranted. Addresses sampling approach at a broad level.

9. Calculate Pass/Fail Rates

   Explains how audit results can be summarized and tracked over time. Discusses using findings to support follow-up review and education planning.