Summary of presentation from Heidi Chamberlin with Sweet Pea Solutions at a recent PMI Conference
Auditing your medical billing department is essential for ensuring accuracy, maximizing revenue, and maintaining compliance in your healthcare practice. Many administrators, billers, and physicians shy away from the term “audit,” but regular check-ins can prevent lost income and uncover inefficiencies before they become major issues. In this guide, we’ll summarize practical advice from billing expert Heidi Chamberlain, including strategies for reviewing coding, payment posting, claim denials, personal billing policies, and more. Whether you’re new to auditing or looking for advanced tips, these insights can help you implement meaningful improvements in your billing workflow.
1. The Importance of Routine Billing Audits
Heidi stresses the necessity of establishing clear, regular standards for reviewing your billing department’s work. Even experienced billers can make mistakes, so a structured audit process is crucial for catching coding errors, missed charges, or denied claims. Regular audits should cover critical areas like charge posting, coding accuracy, payment posting, insurance follow-ups, and reports. The goal isn’t just to find mistakes, but to foster a culture of accountability and continuous improvement.
2. Master Coding, Modifiers, and Insurance Guidelines
A significant aspect of billing audits involves reviewing the appropriate use of CPT codes, modifiers, and insurance guidelines. For example, after-hours and holiday billing codes (like 99050 and 99051) may be missed opportunities for additional revenue if not applied correctly. Modifiers, such as 25, 59, 76, 24, 52, and 50, are frequently misunderstood or misused, leading to denials or lost payments. Auditors should ensure that staff document appropriately and apply modifiers as required—especially for scenarios like sick visits paired with well checks or repeat procedures.
3. Improving Denial Management, Payment Posting, and Write-Offs
Auditing must cover how quickly and effectively your team addresses denied claims. Denials should be corrected and resubmitted immediately, not left in a backlog. Likewise, payment posting should be timely and reconciled with bank deposits to ensure nothing is missed. Regular review of write-offs and full-pay claims (where claims are paid at 100% or written off completely) can identify missed revenue and coding errors. Best practices include tracking explanations for all write-offs, investigating large ticket items, and updating charge amounts if claims are consistently paid at 100% without adjustment.
4. Establish and Enforce Strong Financial and Billing Policies
Your financial policies regarding self-pay discounts, newborn enrollment, copay collection, credit cards on file, and coordination of benefits (COB) should be clearly defined and consistently enforced. Bill for all services rendered, even if an insurance company typically denies them—you may eventually get paid, especially as payer policies evolve. Use protocol and documentation templates for scenarios like COB or newborns, and ensure staff handles refunds, take-backs, and patient responsibility in compliance with both state and payer requirements. For patient collections, proactive approaches such as clear scripting at the front desk and scheduled follow-up cycles help improve recovery rates.
---
5 Practical Takeaways for Effective Billing Audits:
1. Audit Regularly: Set a monthly or quarterly schedule to review charge posting, coding, denials, and payment posting. Use checklists and reports to guide your review.
2. Educate and Empower Staff: Ensure billers understand the correct use of modifiers, up-to-date payer guidelines, and how to work denials efficiently. Ongoing education is key.
3. Bill for Everything: Submit claims for all performed services, even those not typically covered; track denials and follow up as insurer payment policies change.
4. Enforce Clear Policies: Ensure your team adheres strictly to documented self-pay, copay, COB, newborn, and collections procedures without exceptions.
5. Focus on Process Improvement: Identify your top revenue or compliance pain points and implement changes gradually—fix the most pressing issues first, then expand improvements step by step.
By implementing these strategies, you can strengthen your billing department, improve cash flow, reduce compliance risks, and build a more resilient healthcare practice. If you have specific billing questions, don’t hesitate to reach out to Heidi Chamberlain or other experienced billing professionals for support.
