Sample Audit Steps

This is what you might expect from our quarterly audits:

1) Request the appropriate number of reports with CPT codes assigned to the reports.

  1. These reports should have dates of service of at least 6 months prior to the audit start date and should be a diverse sampling of the type of work the group performs.
  2. It is imperative these reports come from the group and not the billing entity to ensure the integrity of the audit process.
  3. The timing of these reports is important as they need to have had adequate time to be processed through the system. By following this timetable, these cases will have made their way through the billing cycle.  Most of these cases will have been paid and processed by the insurance carriers.

2) Receive cases from physician.

3) Create the case audit worksheet.

4) Assign a Reference Number to your report #1 through #999.  This number will also be handwritten on the report.

5) Create and password protect an excel worksheet utilizing the audit excel template and preferred VBS password.

6) Enter Ref Number.

7) Enter Accession or Charge Tracking Number.

8) Enter Patient Name.

9) Enter Date of Service or Specimen Date.

10) Create a copy of this spreadsheet for use later in the audit process.  On the sheet that will be sent to the biller, delete all the other columns from the spreadsheet.

11) Send the audit worksheet and a request for documentation from the billing entity.

12) Request HCFA form.

13) Request Explanation of Benefits from Primary and Secondary Insurance with adjustment codes.

14) Itemized statement for self-pay accounts.

15) Transaction screen showing charges and payments for the case.

16) Once this is sent, allow 4 weeks for the billing entity to pull the documentation.

17) Receive Initial Case Information From biller.

18) Note the date received on the audit checklist.

19) Match Case Information (received from the billing entity).

20) Attach the biller’s documentation to the reports received from the physician’s office in the following order:

  1. Surgical Report
  2. HCFA-1500 form
  3. Explanation of benefits
  4. Transaction screen

b) On the audit worksheet that was originally saved you should see all of the following columns in the file

  1. Report CPT codes
  2. Billed CPT codes
  3. Rendering Physician
  4. Place of service
  5. Modifier
  6. Primary Insurance
  7. Date filed by billing
  8. Date primary payment posted
  9. Date account paid to zero
  10. Questions
  11. Biller Response
  12. Notes
  13. Final Remarks
  14. Final status
  15. Affected Balance
  16. DOS to Filed (pre-populated formula)
  17. DOS to Posted (pre-populated formula)
  18. DOS to Zero Balance (pre-populated formula)

21) Review and enter data from the case as follows.

22) Enter the Report CPT codes from the report into the column labeled “Report CPT.”

23) From the HCFA-1500 form, review and/or enter the following:

24) Box 24A – confirm date of service.

25) Box 24B – enter Place of Service onto the spreadsheet.

26) Box 24D – enter CPT codes and modifiers onto the spreadsheet.

27) Box 31 – enter the rendering physician name.

28) Confirm modifier Professional (26) or Blank (Global) according to the Group’s set-up

29) Check 59 modifier is being used appropriately. The 59 modifier will be applied to a separate distinct procedure that is performed on the same day as another.  The 59 modifier is applied so that the insurance carrier understands this is a distinct separate procedure and not a duplicate.

30) Enter Units from Box 24G.  (If this is a self pay account, this information will typically be on the itemized transaction screen).

31) Enter primary insurance from the upper right hand corner in the space labeled “Carrier.”

32) Confirm the dollar charge Box 24F is according to the Group’s fee schedule.

33) Compare ‘Report’ CPT codes to ‘Billed’ CPT codes.

34) If there is a discrepancy in CPT codes or number of units, question the difference in “Remarks” Column.   Leave status blank.

35) Review the explanation of benefits from the primary insurance carrier.

36) Enter the date of the response from insurance (i.e., date of the insurance check, date received, etc.  This will indicate the amount of time taken to file insurance) in column K.

37) Review that all units were allowed by the insurance carrier.

38) Review that all units were paid by the insurance carrier.

39) If units were not paid or denied, question the difference in “Remarks” Column.  Leave status blank.

40) Note unpaid amounts such as Co-insurance and/or Patient Responsibility.

41) Review that adjustments are not being made for insurance carriers with which the group is not contracted.

42) Check adjustments against the client agreement listing for contracted carriers.

43) Review allowed amounts by insurance carrier from the information provided on the Explanation of Benefits (found on Payor Analysis tab).

44) Build your top codes, the group’s charge, and two years of Medicare rates.

45) Enter the first insurance company’s rate schedule.

46) Calculate what percentage the payer’s rates are as a portion of current Medicare.

47) Ensure CPT allowed amounts are being paid according to the managed care contract reimbursement language.

48) Enter the appropriate allowed amounts under the appropriate payer.

49) Note cases where discrepancy occurred for follow-up by color coding payments less than Medicare and payments that are paid less or more than the carrier fee schedule.

50) Review the transaction screen from the billing entity.

51) Confirm the date that the charge was filed to insurance and place in the spreadsheet on column J.

52) Confirm that the appropriate payments from insurance were posted in accordance with the explanation of benefits.

53) Confirm that the appropriate adjustments from insurance were posted in accordance with the explanation of benefits.

54) If payments or adjustments were not posted correctly, question the difference in ” Remarks” Column.  Leave status blank.

55) Review account balance for secondary insurance and/or Patient Responsibility left on the account.

56) Ensure that secondary insurance or patient responsibility balances are not being written off by the billing entity in error.

57) If the account has an unpaid or open balance, question the account in “Remarks” Column.  Leave status blank.

58) For all secondary balances paid, list that final date in column L.

59) Review and note other patients listed on explanations of benefits for any issue trends.

  1. modifier issues, denial issues, contractual payment issues.

60) Review all cases received in the audit as above.

61) Note cases without issue as “OK” in the status column.

62) Save a copy of the exception/discrepancy report to send to the billing entity.

63) Send initial questions to biller with specified return by date in two weeks’ time.

64) Request response from billing entity in column labeled “Biller Response.”

65) Request additional documentation from the biller for unresolved cases with Remarks.

66) Receive and review additional information or comments from the billing entity.

67) Review additional information if account was billed correctly.

68) Review common trends as to why the miscellaneous cases were incorrectly billed.

69) Is there a large problem that needs to be addressed?

70) Decide if audit is complete with the information received.

71) Any additional pertinent information pertaining to the group’s billing, set up, and/or issues found can be listed in the next tab on the spreadsheet labeled “Notes.”

72) Categorize trends and notate specific case numbers in the “Summary Tab.”