What Are Medical Billing Audits?

Medical billing audits are performed to ensure that medical providers are properly billing insurance companies for procedures. Audits of medical billing may be conducted for a number of reasons. Some reasons why a medical provider may be audited include:

  • Improper procedural and diagnosis coding. This can send a red flag to an insurance bill reviewer, and that can lead to an audit.
  • Protection from fraudulent claims. Fraudulent claims can include billing for procedures that never occurred.
  • Issues with unbundling procedures. If an insurance company has a code that includes multiple components of a procedure, that code should be used and a provider should not bill separately for those components.
  • Use of outdated codes for procedures. Sometimes a medical provider may not have the most up to date codes for procedures. If they use old codes, they risk having their claims denied and the insurance company may become suspicious of the activity.
  • Determining medical necessity. If an insurance company questions the medical necessity of a procedure they may deny the claim. If a provider is constantly having claims denied for medicl necessity they may be targeted for an audit.

Notification of an Audit

If a provider and an insurance company cannot resolve billing issues, the insurer may decide to conduct an audit. These audits can occur on site at the provider’s location. The audit includes review of medical records, including medical bills. The review can identify and answer questions that the auditor may have regarding the provider’s billing.

Do I Need a Lawyer?

If you are subject to a medical billing audit, it may be a good idea to consult with an attorney. An attorney experienced with defending medical providers and handling medical audits.

If you require a medical law attorney for your legal matters, call Paul E. Walker, an experienced New York City OPMC & OPD Lawyer. Please contact the Walker Medical Law firm to set up a free initial consultation.