Conducting an internal chart audit require team effort to plan, execute and analyze the results. You will get far more out of the audit by involving team members from different departments and presenting it as an exciting time to learn more about the inner works of the clinic visit and their implications on practice finances. A team of five is perfect; a receptionist or scheduler, a biller, a nurse or medical assistant, a medical records or data entry person and a physician or other provider.
Begin by gathering five random patient records per each provider and selecting one date of service for each patient; the date of service should be three to six months prior. This allows adequate time for insurance processing and receipt of third party payment on the records being reviewed. Staff should break into teams of two – preferably one administrative staff and one clinical staff person. Each team should review a minimum of five charts and document discrepancies. When the review is completed, they should analyze the results to determine if the same errors are recurring or if there are different areas of the practice or service where problems occur. They should then calculate the potential cost of the errors over a twelve month period. The next step is to make a recommendation on how to approach correcting the deficiencies for long term benefit.
Common problems detected:
- Discrepancy in evaluation and management level of service (E&M code)
- Wrong diagnosis
- Missing dictation
- Incomplete charge slip
- Missed office charges: Procedures, lab, x-ray
- Missed hospital charges: ER visits, consultations
- Insurance write offs taken that are not justified (payment overlooked or discounted by payer)
- Patient balances written off on Medicare patients
All of these problems have the potential to both cost your practice money in the short term (e.g., by causing denials or delays or down-coding) or in the long term by triggering an audit by Medicare or a private payer. By conducting your own internal audit, not only will your staff learn what kinds of mistakes you’ve unwittingly been making (and be able to correct them), everyone will understand better how all the parts of the practice work together. This can be invaluable in helping minimize conflicts and “the blame game.”
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