Account Audit Procedure

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Below is a very complete audit procedure. You don't always have to do every step, but if the step you are on is just not making sense, go back and fill in the missing steps brings clarity. In my consulting work, this is mostly what I do.

Claim Audit

How to audit summary:

• 4 preliminary steps: Which account, posting & filing backlogs, ledger clean.
  
• 4 checks: service delivered, patient co-paid, claim sent, insurance replied
• 4 results: Paid Fair, Paid Poorly, No Payment, No Answer
• 4 actions: Patient collect, re-bill, write-off, defer

Four answers only every charge on the ledger

They paid a fair amount =
Correct coding, correct claim reading, fair benefits, correct identification.
To Do: bill patient co-pay and/or write off the balance.

They paid a poor amount. =
Incorrect coding, payer misread the claim, token benefits
To Do: Analyze and correct the reason for poor payment.

Paying nothing =
Incorrect identification, insufficient proof of service, no insurance or exhausted benefits or deductible
To Do:

No EOB:
wrong insurance, lost, not billed, or too recent for payment.
To Do: call to verify coverage and billing address and claim status, send or re-send the bill, or defer action.