Creating an internal audit schedule for billing compliance isn't just a good practice—it's a necessity for any healthcare practice serious about minimizing risk and maximizing revenue. But let's face it, building a comprehensive and recurring audit calendar is anything but straightforward. Payer rules aren’t static and neither are coding protocols. If you’re not on top of it, things can go south fast.
Define Your Audit Scope
Before diving into schedules and calendars, get clear about what you’re auditing. The most common areas include coding accuracy, charge capture, and compliance risk areas. Coding errors alone cost practices thousands of dollars annually due to denied claims and delayed reimbursements. Your scope should focus on what historically gives you trouble while also considering upcoming regulations.
Coding Accuracy
Start here because errors in coding can lead to denied claims, delayed payments, and compliance issues. Evaluate your top 10 most frequently billed CPT codes first—this is usually a good indicator of where errors are likely to occur. Include newer codes as well, since unfamiliarity often leads to mistakes.
Charge Capture
Are all services being captured? Probably not. Missing charges are silent killers of your revenue cycle. An audit should include reviewing visit notes against charges submitted. Cross-reference with previous months to spot any patterns or recurring issues.
Compliance Risk Areas
What gives your compliance officer night sweats? Focus there. This could include ensuring that documentation supports the billing codes used or verifying that preauthorization requirements are being met. If Medicare makes up a significant portion of your revenue, their guidelines should guide your compliance audits.
Establish Audit Frequency
Once you know what you'll audit, the next step is deciding how often to do it. Coding and charge capture audits should occur quarterly at a minimum. Compliance risk audits, due to their complex nature, might be best suited for biannual reviews.
But, some areas might need more frequent attention. For instance, if you’ve recently integrated new billing software, a monthly audit might be prudent until everyone’s comfortable.
Create the Audit Calendar
Now, translate your audit scope and frequency into a tangible calendar. Use a simple spreadsheet or project management tool to map out the entire year. Assign months to specific audit types and add reminders for internal review meetings.
Monthly Tasks
These are typically lighter audits, great for ongoing monitoring of frequent errors. Consider monthly coding spot-checks—maybe 10 randomly selected claims. Keep an eye on any recent coding changes or payer-specific guidelines that came out.
Quarterly Tasks
Larger audits fall here. Break down your coding accuracy review and charge capture task into quarterly projects. This will give you a broader picture without overwhelming your team.
Biannual or Annual Tasks
These are the deep dives. Spend more time here looking into compliance risk areas or conducting a thorough review of denial trends. Pair this with educational sessions for staff on the findings.
Assign Responsibilities
You’re not doing this alone. Each audit should have a designated lead, whether that’s your billing manager, a compliance officer, or a team of specialized billers. Define roles clearly, so nobody’s wondering who’s doing what when the audit date rolls around.
Involving more team members opens the door for valuable insights, but it also means more coordination. Use software like Slack or Microsoft Teams for communication and progress tracking.
Review and Revise
An audit schedule isn’t a "set it and forget it" kind of thing. After each audit, review the results collectively. What did you find? What actions need to be taken? Update your schedule based on these findings. Maybe a monthly audit needs to become a weekly one—or vice versa.
Track Outcomes
Metrics are your friend here. Track the results of each audit. For coding accuracy, measure error rates pre- and post-audit. For charge capture, look at revenue trends. Spot positive changes? Good. If not, time to dig deeper.
Keep an Eye on Payer Trends
Rules change. Payer policies evolve. If you’re not staying updated, your audit schedule will quickly become outdated. Subscribe to payer newsletters, attend webinars, and participate in industry forums. Then incorporate any changes into your audit plan.
Final Thoughts
Creating an internal audit schedule for billing compliance is a dynamic process. It requires commitment, but the payoff in reduced errors and maximized revenue is too significant to ignore. Keep it flexible, keep it relevant, and most importantly, keep at it. The landscape of billing compliance is always changing—make sure your audits are timely and informed.
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