Medical Billing Audits In Florida

A Doctor utilizing Bloom for Medical Billing audits

Efficient medical billing is essential to the survival of any healthcare practice. It involves correctly reporting diagnoses, procedures, and supplies to commercial insurance companies and federal payers.

Unfortunately, too many healthcare practices and facilities fail to stay organized. They also struggle to keep up with the latest federal regulations as they pertain to proper medical billing. As a result, they risk extensive scrutiny by federal authorities. Read on to learn more about the ins and outs of medical billing audits, and how medical billing audits in Florida might help your practice.

What is Medical Billing?

Medical billing is the process of generating healthcare claims to submit to insurance companies. This ensures the healthcare practice or provider gets paid for services rendered. Medical billing also includes the translation of healthcare services into a billing claim. This is known as “medical coding.” One of the final steps in medical billing requires a “follow-up” with the insurance company to ensure prompt payment.

What Is a Billing Audit?

A medical billing audit is the process of evaluating a healthcare practice’s clinical documentation. Not unlike a tax audit, a medical billing audit looks over all health records the practice maintains. This includes a review of all medical billing data submitted to the health insurance companies to ensure the practice is correctly identifying and coding services. A review of medical billing data also attempts to correct any incorrect billing on the part of the healthcare practice.

During a medical billing audit, the practice will likely be asked to provide clinical records. These records can include patient medical records, X-rays, and lab reports. They can also include financial records, like an accounts receivable ledger or spreadsheet, as well as policy-related documentation required by government bodies like the Centers for Medicare and Medicaid Services (CMS).

Audits are conducted either before or after medical claims are sent to insurers. Because medical billing is related to a healthcare practice’s bottom line, periodic medical billing audits are an essential workplace practice.

A woman benefitting from Medical Billing Audit restructuring in Florida through Bloom Consulting.

Pitfalls of Improper Billing

Like any aspect of the U.S. healthcare industry, medical billing is subject to constant updating and refinement. This means that, unfortunately, there is no “silver bullet” solution when it comes to keeping abreast of the changes in medical billing and coding.

As a result, the risk of not having a medical billing policy aligned with current laws and regulations is practically constant. Perfectly well-meaning practices in the Sunshine State have been knocked with fraudulent claim charges through simple coding or billing errors. Effective medical billing audits in Florida would have helped them avoid these charges.

Types of fraudulent medical claims include:

Billing for uncovered services. Depending on the patient’s plan, some services deemed necessary by the healthcare provider may not be covered by an insurer. When the insurer is billed for such a service, it could lead to that billing being considered fraudulent.
Billing for services that were not provided. Sometimes, healthcare practices bill for services they did not actually provide. Whether this stems from an internal communications issue or a careless mistake in medical coding, the claim may trigger an investigation.
Upcoding. Upcoding occurs when a healthcare practice bills for more than was provided. This can include “rounding up” billing to increase reimbursement or billing for more expensive medications when the generic was used. This is a complex type of healthcare fraud that also happens to be extremely common.

Benefits of Medical Billing Audits in Florida

While it may sound like a headache for your practice or accounting team, medical billing audits have their benefits. These benefits include:

Coding. When done right, a medical billing audit can identify and correct coding problems before the government or insurance payers challenge inappropriate coding. This saves the practice from being paid a visit by such government-sponsored auditors as Recovery Audit Contractors (RACs) or Zone Program Integrity Contractors (ZPICs). A billing audit can also point out where the coding staff might need additional instruction or training. This reduces confusion and builds confidence.
Administrative. Incomplete or inaccurate medical coding billing creates extra work for a healthcare practice’s administrative staff. This occurs as claim payments are reprocessed and improper payments are corrected. An effective medical billing audit identifies reimbursement deficiencies and other areas where compliance might be more smoothly maintained. Also, opportunities for increased medical reimbursements may turn up, providing boosts in revenue.
Clinical. By being able to track its services properly and with confidence, a healthcare practice can focus again on its care quality. With improved patient experiences, better patient outcomes and a smoother revenue cycle follow.

Internal Versus External Audits

Medical billing audits performed by an internal team can be an asset to healthcare practice. it offers welcome feedback and information on how to improve before any government bodies come knocking. But for those practices not large enough to field their own internal audit team, an external or outsourced medical billing audit might be the way to go.

Plus, external billing audits can spot inefficiencies without worrying about their impact on the practice’s bottom line or workplace culture. A small, busy healthcare practice operating in the Sunshine State might see huge benefits from an external medical billing audit in Florida, like the kind provided by Bloom Consulting.

Consider Bloom Consulting for Medical Billing Audits in Florida

If your healthcare practice is experiencing trouble with medical billing, or if you are just looking for a “check-up” regarding your billing Bloom Consulting has the resources to assist you. Our team is well-versed in the language of billing, revenue management, and compliance. Our consultants can meet with your administrative team to assess your practice’s needs and offer valuable guidance.

Contact us today for professional external medical billing audits in Florida. It may turn out to be one of the best things you can do for your healthcare practice.

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