Auditing Medical Charts and Documentation
There are many reasons why medical charts and documentation would need to be audited. One reason could be due to an insurance audit or request.
Another reason could be due to an increase in patient information being found in other patient charts, which can occur in offices that are using charts or electronic medical records or scanning.
Although auditing can seem intimidating to providers, it can provide insight into a practice’s organization and/or it can help reduce liability. Carelessness in documentation can lead to potential medical and financial liability for the practice.
It is important for all providers to do an audit or have their billing company, if they have a certified coder on staff, or an in-house certified coder audit medical charts and documentation to ensure that the correct measures are being taken to be efficient and not violating HIPAA rules.
Auditing helps to find out is the provider is providing accurate treatment and is in compliance with the rules of OIG and HIPAA/HITECH among other federal and state rules and regulations. Accuracy and compliance is important because it helps providers provide patient with not only appropriate care, but necessary care as well.
The best benefits of providing accurate and compliant documented charts are patient satisfaction and an improvement in revenue, which means fewer denials.
Proper Documentation leads to Accurate Coding which leads to Becoming Fully Compliant which leads to a Successful Practice.
Once an audit has been completed, there should be a report of the findings as well as a discussion of the key findings and what type of education and training will needed to be implemented to get back on track.
It is important for providers to make sure that whatever they are billing was actually done. The Office of Inspector General (OIG) is cracking down on the number of providers that are committing fraud and the cost of being under investigation by OIG leads to a hefty judgment against the provider.
The work does not just stop here. You have to maintain this implementation and continue to have regular audits to ensure success.
Contact us today at (877)353-8819 to find out how we can help you properly audit your medical charts and documentation before the insurance decides to audit you.