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  • Writer's pictureRicki Owens

Your go-to guide for Revenue Cycle Management Audits


Revenue Cycle Management Audit guide


For medical billing practices, landing new patients translates into avenues for future profits, but at the same time, the looming presence of Audits to your inboxes and morph the endearment towards anticipated influx of revenues into a pool of anxiety.


With this, you begin the vicious cycle of second guessing your operations- were your billing practices optimal? Is there a chance your practice could face financial penalties? Was there something you could have done with respect to your denial management strategies?


This is a classic roller coaster loop of Revenue Cycle Management that glides through the heights of new business opportunities but also brings with it the stomach-churning drops of forthcoming financial trenches. But with optimal preparation and presence of mind, RCM audits can become crucial areas of opportunity to recognize measures that can be improved and further streamline revenue cycle performance metrics.


As you read further into this guide, we will equip you with the insights to not just understand but also approach the terrifying RCM audits with confidence. Exploring processes like the types of audits, the minute details of the process and some lesser-known strategies to ensure a smooth auditing process, let’s conquer the roller coaster of Revenue Cycle management audits together!

Beyond the Basics: Exploring what Revenue Cycle Management Audits are


Let's clarify the diverse types of RCM audits you might encounter:

  • Internal audits: Within your organization, your own group can perform internal audits to find gaps in internal control and verify adherence to rules.


  • Payer audits: Insurance companies may conduct payer audits to confirm that your billing and coding procedures are accurate. These may be centered around certain services or an arbitrary sample of claims. According to a recent study, a staggering 82% of physicians reported experiencing a payer audit in the past year.


  • Medicare Administrative Contractors (MAC) Audits: These audits are carried out by government-contracted organizations that manage Medicare claims, and they are comparable to payer audits.


It's critical to comprehend the kind of audit you're dealing with because it will dictate the precise emphasis and paperwork needs.

The Nitty-Gritty: What Happens During an RCM Audit?


Here's a breakdown of what you can expect during a typical RCM audit:

  1. Notification and Request for Documentation: A notification is generated by means of contact initiated by the auditor, followed by them providing a detailed list of what records they need from you. This list entails patient charts, coding logs, and supporting documentation for specific claims, etc.

  2. Review and Analysis: A meticulous scrutinization of all submitted documentation is taken out by the auditor to ensure that your RCM systems are accurate and up to date with compliance and coding & billing regulations, which encompasses sampling a number of claims that can be considered statistically viable.

  3. Findings and Potential Outcomes: Once the review is carried out, a report outlining all resultant findings is delivered by the auditor and depending on how severe the internal or operational issues are, you may receive:


a. Clean Audit: Nothing to worry about, your billing practices are compliant.

b. Educational Findings: You receive this if the auditor finds minor areas for improvement but not enough to impose penalties. 

c. Overpayments: This entails repayment to insurance companies if coding  errors that result in overpayments are recorded in the audit. 

d. Extrapolation and Penalties: This is perhaps the worst situation for an audit- an auditor finds serious computation errors during the audit, utilizes the information to estimate the total amount of overpayments for all of your claims, and imposes heavy financial penalties. 


Strategies for a Smooth RCM Audit

While maintaining accurate documentation and coding practices is crucial, there are additional strategies to ensure a smoother audit experience:

  • Develop a Strong Internal Audit Program: Undergoing regular internal audits keeps you prepared and helps identify and regulate issues before they grow into unsalvageable pain points in an external audit.


  • Invest in Ongoing Compliance Training: Keeping the coders and billing workforce up to date with coding and billing regulations in your organization is key to maintaining compliance standards.


  • Build Relationships with Payers: transparency in communication when it comes to the payer population can greatly alleviate discrepancies and prevent the need for audits altogether.

  • Leverage Technology: RCM systems that automate and streamline workflows, minimize the error rate risk and offer built-in compliance checks and audit traits make incredible investment opportunities that ease the task of managing documentation.


  • Prepare a Dedicated Audit Team: Another fruitful investment comes with putting together a team of experts who possess the knowledge and resources to handle audit processes efficiently and are comfortable with your coding and billing approaches to help them access required documentation readily.


  • Practice Makes Perfect: Periodic mock audits help in practicing for perfection by helping you recognize and rectify any potential weaknesses in your RCM processes and refine documentation as well as team members to respond to auditor enquiries more informedly.


The post-audit process is critical, regardless of whether you find areas for improvement or receive a clean audit. Examine the auditor's findings carefully and then develop a detailed plan of action to fix any problems found.

Some Additional Tips for Post-RCM Audit Success:


Step 1: Initiating a corrective action plan by developing a detailed blueprint describing how you intend to address the identified issues, including timelines, responsibilities and resource allocation.

Step 2: Periodically monitor the progress and efficacy of your corrective action plan to see if it has addressed the root cause of the issues or if additional measures are required.

Step 3: Learn from every audit and view them as opportunities to inculcate valuable insights to maintain maximum efficiency and make ongoing improvements to your revenue cycle procedures.

Why you should Invest in RCM Experts


Investing in outsourcing your revenue cycle operations to reputed RCM service providers ensures you don't have to navigate through the complexities of RCM audits without support. Building a healthy and lasting relationship with these experts can significantly enhance your chances of a smoother audit experience.


RCM experts possess extensive experience and in-depth knowledge of regulations pertaining to coding and billing and have also comfortably dealt with diverse types of audits in the past, making them dependable for your requirements. They can help you streamline the entirety of your revenue cycle, minimizing errors and ensuring appropriate documentation from the beginning.


Not just this, reliable RCM service providers fully leverage the inclusion of technology into advanced solutions that help automate tasks, enhance the accuracy of operations and streamline management of documentation.


A capable and lasting outsourced RCM partnership lets you concentrate on the prime goal of providing exceptional patient care and the partners focus on handling back-end complexities, ensuring your practice is well-positioned for financial success and thrives through any potential audit.

By understanding the distinct types of audits, familiarizing yourself with the audit process, and implementing proactive strategies, you can approach them with confidence and ensure that the experience of an RCM audit doesn’t become a source of stress for you. Remember, these audits can be valuable learning opportunities, enabling you to refine your revenue cycle processes and optimize your financial performance.


Do you want to dive deeper into the intricacies of well-established RCM services that can holistically transform your healthcare firm’s revenue cycle? Schedule a call with our RCM experts today! We will work closely with you to develop customized RCM solutions that ensure compliance, maximize efficiency, and pave the way for long-term financial success for your medical practice.

Let us turn your RCM rollercoaster ride into a smooth and steady climb to prosperity! You can reach out to us here

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