We Guarantee Improved Medical Billing Efficiency, Effectiveness & Compliance

97% Retention - Expert Auditors

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of claim denials are overturned
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improvement in net patient revenue
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of claims are collected within 90 days or less
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clean claims rate
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average reduction in AR days

Medical Billing Audit Services

Samoya Skeete
Samoya M. Skeete
Certified Coder and Healthcare Auditor
Medical Billing Audit Team Lead

Chris Anderson
Chris Anderson
Chief Compliance Officer
Medical Billing Audit Team Lead

A medical billing audit can help healthcare providers in two different ways. It can:

  1. Ensure the company’s billing is in compliance with its legal and contractual obligations and, if it is not, reveal the deficiencies before someone else does so they can be fixed before liabilities accrue, and
  2. Uncover any inefficiencies in the billing process that are leaving money on the table or are costing the company extra.

The auditing professionals at Fortis Medical Billing have extensive experience conducting billing audits in the healthcare sector for a wide variety of providers.

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What a Medical Billing Audit Entails

There are numerous steps in the medical billing process, and they are not restricted to the back rooms of healthcare facilities. Almost from the instant a patient enters the doors, the billing process begins – and can fail in ways that expose your company to lots of liability and financial pain. For example, errors or inefficiencies in the patient intake process can set things up for a serious problem when the medical bill is, eventually, sent out for the goods or services that the patient wound up receiving at your facility.

A medical billing audit can explore one or all of the steps in that process. Each type of medical billing audit would require something different, but the goal is always the same: To ensure the correct steps are required and are being followed.

Just a few examples of what a medical billing audit can look like are:

  • Reviewing patient intake policies, forms, and procedures to ensure their medical issues are adequately documented so the healthcare company can back up the provision of services against claims that they were not medically necessary
  • Checking the facility’s recordkeeping practices to ensure that everything is being retained in compliance with applicable laws, regulations, and contractual obligations
  • Medical billing employee trainings are reviewed for continued accuracy and are updated as necessary
  • Reviewing patient charts to make sure they are accurate, include all of the necessary information to rebut an allegation that services provided were not medically necessary, and are retained as required by law
  • The medical bills submitted accurately reflect the care or services that were provided

Hopefully, these audits do not uncover any problems. Even if this is the case, though, and nothing bad is found, you and your company still benefit from the peace of mind that this knowledge leads to.

If issues are detected, the next step would be to correct them. Experienced auditors will have seen nearly every way that the medical billing process can become tainted with noncompliance or inefficiencies. They will have a good idea of how to go about bringing the process back into compliance, and how to do it with as little cost to the company as possible.

Auditing Can Ensure Compliance

The main goal of a medical billing audit is to make sure that the bills that do get sent out by the provider are able to withstand scrutiny and any allegations of healthcare fraud or inadvertent billing errors that may follow.

It’s all about mitigating risks.

Just a few of the findings that a thorough billing audit can help you avoid are:

  • Upcoding, where the wrong medical code is used on the bill (if a billing audit finds these, a medical coding audit should be the next step)
  • Unbundling, where the insurer is billed for individual services that are generally bundled together at a discounted price
  • Double billing, where more than one bill is submitted
  • Phantom or fake bills, where bills are sent for medical care that was not actually provided
  • Allegations that the bills are for medically unnecessary care

By reviewing your healthcare company’s billing practices and comparing its records of billing statements against other retained information, an audit can reduce the likelihood that your company is faced with costly allegations of misconduct and the steep penalties that these claims can lead to if they are substantiated.

The High Costs of Noncompliance

Healthcare providers can face huge problems if the insurance companies that they deal with even suspect them of billing errors or healthcare fraud.

If a healthcare company finds even an isolated billing error, it can use the incident to justify its own audit to ensure that it is, in fact, an isolated one. That audit on its own can be extremely inconvenient and intrusive.

However, if the findings of the audit are not pristine, insurance companies will often implement safeguards, such as by requiring prior authorization, to the billing approval and payment process to prevent further errors from taking the company’s money. Those safeguards, however, can slow down the payment process to such an extent that it may no longer be worth dealing with the insurance company. Furthermore, the increased scrutiny can detect other errors that may have been overlooked before, increasing the stakes even higher.

Meanwhile, the insurance company will demand that the full amount of its overpayment be returned – including overpayments on bills that were made months or even years in the past.

If worse comes to worst, the insurance provider may exclude your healthcare company from its programs, depriving you of its roster of policyholders, some of whom may be your most reliable clients. Insurers can even forward what they think is evidence of healthcare fraud to law enforcement agencies.

Other Inefficiencies Can Be Spotted As Well

While compliance and avoiding liability for it is the chief goal of a medical billing audit, an audit can also uncover inefficiencies in your business that are costing your company lots of money. A few examples include:

  • Unbilled services, where medical care was provided but was not billed
  • Underbilled services, where care was provided but could have, or should have, been billed higher
  • Uncollected bills, where the bill was sent but it was never paid in full
  • Inefficient billing practices or procedures, which can be sped up or streamlined to reduce personnel demand

In some cases, a medical billing audit can reveal substantial amounts of money that are unknowingly being lost every year.

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Frequently Asked Questions About Medical Billing Audits and the Services that Fortis Medical Billing Can Provide

Are External Audits Better Than Internal Ones?

It depends on your needs, concerns, and goals. However, external auditors offer several important things that internal ones cannot.

An internal audit is one that is conducted by employees at the company, while an external audit is done by a professional auditing firm.

Because they are employees, internal auditors are going to be more familiar with the medical billing process that is used, as well as where to find important information and who to talk to. However, that familiarity is a double-edged sword, as an internal auditor’s workplace relationships can make them unwilling to reveal serious issues and become unreliable sources of information. Furthermore, internal auditors are less likely to think critically about their employer’s existing billing practices, and their employment relationship also means that they are very unlikely to have seen many other billing protocols or setups to compare their own to.

External, professional auditors, on the other hand, will have seen lots of different ways to do medical billing through their audits of other medical providers.

What is Healthcare Fraud?

Healthcare fraud is unlawfully using deceit to obtain money in the healthcare system. If done intentionally, it can be a crime.

This is important to understand because medical billing issues frequently lead to claims of healthcare fraud by the insurance program that has been overpaying for healthcare services. Whenever insurers detect billing problems, they are very quick to jump to the idea that it was intentionally done. That presumption of fraud can be a big problem for healthcare companies, as they can see serious repercussions from the protective measures that insurers take even before their investigation has gotten very far.

It is not uncommon to see healthcare providers suffer from the mandatory prior authorization of their bills while the insurance company’s investigation is pending – even if that investigation finds no evidence of wrongdoing.

What Sets Fortis Medical Billing Apart from Other Healthcare Auditing Firms Out There?

Fortis Medical Billing is staffed with medical auditing professionals as well as former federal investigators from some of the top law enforcement agencies in the world, including the FBI and OIG. That prior experience lends us a huge leg up on our competitors, as we know what federal agencies will be looking for should they learn of allegations of healthcare fraud.

That insight is essential for the auditing process, as it allows us to notice signs of noncompliance that other medical billing auditors might miss, and propose solutions that we know will be effective, having seen them put in place in the past.

In addition to our prior law enforcement experience, Fortis Medical Billing also has numerous experienced healthcare auditing professionals from other federal agencies, most notably the Centers for Medicare and Medicaid Services (CMS). Their insiders’ understanding of the field of public health insurance can help you navigate those waters and come into, and remain in, compliance with the complicated regulatory obligations that CMS imposes on healthcare providers like your company.

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Fortis Medical Billing: Medical Billing Auditors for Your Healthcare Company

Fortis Medical Billing is a firm of professional auditors with extensive investigatory experience in the healthcare industry. Our team has helped a wide array of healthcare companies audit their billing practices, including:

Many of the auditors on our staff are former investigators for some of the most powerful and highly regarded law enforcement agencies in the world, including the:

  • Federal Bureau of Investigation (FBI)
  • Internal Revenue Service (IRS)
  • Department of Labor (DOL)
  • Office of Inspector General (OIG)
  • Department of Defense (DOD)
  • Drug Enforcement Administration (DEA)

Contact us online or call our office at (866) 808-4160 to get started on a medical billing audit at your healthcare company.

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