Introduction

Medical auditing is the systematic evaluation of a healthcare organization’s performance. Most parts of healthcare are able to be audited, while many audits concentrate on payer payment methods to determine compliance with subscriber criteria as well as federal and state regulations. The medical audits from BlueLogiQ play an important part in a healthcare organization’s compliance plan by finding faults and designing corrective procedures to eradicate them.

The Goals and Benefits of Medical Audits

Enhancing Care Delivery

Clinical auditing provides a framework for collaborative and systematic improvement of patient care quality. You can spot developing patterns through a vendor compliance audit, which allows us to identify dangers and take action before they become a greater problem. Auditing helps you to determine which services are working well and encourage good practice, which enhances the quality of services and outcomes for users, as well as indicates which services need to be improved.

Target Areas for Improvement

The goal of quality improvement (QI) is to enhance the patient experience. Although audit is frequently more clinical, QI may focus on more general concerns such as the accessibility of beverages that are hot in A&E. The plan, do, research, and act framework may be used to do QI. These cycles are incremental and have brief spans, allowing for rapid progress.

Utilizing Audit Findings

Clinical personnel, healthcare organizations, and patients all want to have information about the quality of care being provided and that adjustments in the treatment of patients are being implemented as needed. Medical audit findings can be used to: 

  • Indicate the standard of care that is offered to patients 
  • Demonstrate that the company is dedicated to enhancing the excellence of care given to patients 
  • Share what has been accomplished achieved with people who were not involved in the auditing process 
  • Help medical professionals reflect on the manner in which the examination was done to discover the manner in which to do future audits of clinical procedures in better ways 
  • Provide confidence to the organization’s board 

Reasons to Perform Medical Audits

Proactive Measures

Medical vendor compliance audits serve as a technique for examining the quality of care delivered to patients. It educates providers on proper paperwork. Check to see if the organization’s policies are up-to-date and effective. Through medical audits, you can improve revenue cycle management. It also ensures that appropriate revenue is collected and protects you from government and payer inspections, malpractice lawsuits, and medical plan denials.

Revenue Optimization

Medical audits undertaken by the provider organization like BlueLogiQ or on its behalf by a third party are critical because they prevent coding and billing problems. Audits not only detect faulty coding but also prevent it from occurring again. Claims mistakes have a compounding effect on an organization and, worse, bring government scrutiny.

Regulatory Compliance

Medical auditing addresses ignorance by exposing areas of noncompliance, and knowledge is a liability. Consider the following in order to comprehend why the service provider’s organization is accountable for recognizing incorrect coding and invoicing practices:

  • A widespread mistake pattern that results in increased reimbursement appears to be fraud as well as may be indistinguishable from fraud and
  • A famous pattern that results in greater compensation for the healthcare provider has the same impact as payer fraud.

Methods of Conducting Medical Record Audits

1. External vs. Internal Audits

Internal second-party audits by BlueLogiQ mostly focus on measuring recent performance and finding areas for improvement. Similarly, external audits focus on serving the integrity and accuracy of financial statements. Choose the right approach that goes best for the industry. 

2. Step-by-Step Guide to Auditing

The decision between a targeted, second-party audit versus an audit at random will be based on which technique best suits the auditor’s objectives.

  • Focused- Focus on a certain service item, supplier, assessment, etc. For example, you might want to audit a particular provider whose reimbursement is going above average. Perhaps your company is plagued by modifier mistakes.
  • Audits at random- refer to extensive examinations, including an example of charts chosen at random to identify compliance issues mirrored in all charts. The sample will be drawn from a certain time frame, ideally within the last three months.

2.2. Defining Measurement Criteria

Determining the audit’s scope requires honing or defining characteristics that determine whether a targeted versus random audit was conducted. If this is the first audit for the practice, you may wish to employ random sampling. Previous audit reports should specify a target area, such as initial visits to offices, discussions, inpatient visits, or specific diagnostic codes if the organization has undertaken previous audits.

2.3. Sample Size Determination

The audit sampling should include a proportion of patient interactions that represent the different types of contacts. Auditing too few documents may skew findings, whereas auditing excessive quantities becomes time and labor-intensive. The typical audit sample size is 10 to 15 charts.

2.4. Recordkeeping Tools Development

When assessing the medical record, it is critical to prioritize efficiency when picking an audit instrument. A surgical audit tool, for example, should be utilized if the auditor is reviewing surgical notes. The instrument must match the practitioner standards if the external auditor is doing an assessment and oversight (E/M) audit.

2.5. Data Gathering

After determining the specimen size and charts, you must collect documentation relevant to the date the service began (DOS) for the charts under examination. Aside from a remark, the medical file regarding the individual’s visit might contain labs, papers, pictures, and other incidental documents. To complete the evaluation effectively, all paperwork is necessary.

2.6. Findings Summarization

Create a short report based on the audit results. Your writing should be thorough and convincing. The reader should comprehend what was audited along with how the audit was carried out.

Determine the number of contacts that were correctly and erroneously documented. Take note of code patterns and faults.

2.7. Data Analysis and Implementation

Analyze your results and identify issue areas when the medical audit is completed, such as:

  • Incorrect code assignment for treatments or services
  • Documentation does not support E/M levels.
  • Incorrect diagnostic codes that do not capture sufficient specificity or demonstrate medical need
  • Modifiers are missing or are being used incorrectly.
  • Incorrect diagnosis connection
  • Services rendered but unbilled

Conclusion

Clinical auditing by BlueLogiQ is a method of determining if care is being given in accordance with standards and informing care patients and healthcare providers about where their experience is doing well and where it may be improved. The goal is to allow improvements in quality to occur where it will prove most beneficial and enhance patient outcomes.