• AHAP Inc.

Compliance Auditing and Education

For healthcare providers which receives payment from a governmental entity or private insurer following compliance regulations is mandatory. Highly functioning organizations and physician practices understand that investing in an effective compliance plan is far less expensive than being subject to such recoupments, fines, and penalties. At the same time, an effective approach to coding & compliance auditing and education is essential for all healthcare providers.


In many cases, providers and practitioners are not aware of their weaknesses when it comes to coding and documentation. Knowledge is power and the more providers are aware of the process, the more effectively they can control the outcome and able to take appropriate action.


An effective coding audit can serve a variety of purposes such as education. It is helpful for a medical practice to understand the complexity of medical coding and billing which is why educating staff and providers is vital and can help the practice set up a quality assurance process.


In many instances when a healthcare provider requests a coding audit, they are looking for lost revenue. They assume if the medical group is losing revenue, it is due to the fact that providers are under-coding. Although this occasionally may happen but most often there is a need for providers to understand the use and selection of appropriate code based on level of care provided.


An appropriate education on proper guidelines of accurate billing and coding practices can address these issues. The approach to coding education is critical to making a difference for the providers. Customized coding/documentation education by certified experts based on results of audit findings is an important first step to initiating behavior change and ongoing documentation improvement.


Providers are not initially taught proper documentation requirements, which is where a Certified Coding Auditor and Educator can assist providers in clinical documentation improvement and demonstrate proper documentation requirements. As well as to ensure that the documentation explicitly identifies all clinical findings and conditions present at the time of service.


While many physicians are initially resistant to the idea of setting aside a block of time for training, an intensive training session is an important first step to initiating behavior change and ongoing documentation improvement. These can be accomplished by:


  • Group Training Sessions. Focus will be on educating providers based on the audit findings related to documentation, coding, and billing requirements. This also allows everyone in the group to hear the same information and share ideas and concerns during open discussion.


  • 1-on-1 Training. Certified Auditor will conduct training with individual provider(s). This can provide specific/focused training and hands-on training based on audit findings and overall documentation requirements. This 1-on-1 training is imperative for providers new to your organization.


  • Monitoring and Support. It is equally important to continue educational efforts and provide support for providers on an ongoing basis. As well as keeping them engaged in the improvement process.


  • Corrective action. Create and implement a corrective action plan to address identified areas of concern. Develop preventive action processes based on the findings of the audit. Audit results should be used to improve physician documentation initiatives.


In summary, medical practice involve significant amounts of clinical documentation and medical claims information. Ensuring accuracy of that information via regular audits is an imperative for risk mitigation and maintaining compliance. it is helpful for a medical practice to understand the complexity of medical coding and billing which is why educating staff and providers is vital.


Recent Posts

See All

TPE and Prepay Audits

Failing a TPE audit can result in onerous actions. Healthcare audits have now resumed to 100-percent capacity – or even 150 percent. All audits that were suspended during COVID have been reinstated. R

Quarterly Clinical Chart Review

Since most patient visits require an E/M code, Evaluation, and Management (E/M) codes are at the core of most physician practices and FQHCs. Qualified health professionals can maximize payment and red