• AHAP Inc.

Internal and External Coding Audits

Regardless of the size, one of the requirements for healthcare organization, medical practices, FQHC and clinics is to establish a medical billing audit plan.


Performing clinical chart audit is an important piece of an effective compliance program. The decision to perform the audits internally or externally is determined by each healthcare organization.


Many healthcare organizations use a combination of internal and external audits to maintain compliance; however, internal auditor is sometimes cost prohibitive for some healthcare organizations. Another problem is finding an auditor with the necessary training and expertise in auditing medical records for accuracy and compliance.


The goal of any audit is to identify issues and help make improvements. Regular audits can help identify mistakes or errors before they become big and costly problems. Chart reviews and claim audits can increase coding accuracy, improve clinical documentation, enhance charge capture.


Benefits of external claim audits.


One of greatest advantage of using an external audit firm is objectivity. An outside audit firm can be more objective and therefore more likely to discover issues such as upcoded or undercoded bills. Recommendations that they provide will be unbiased and more likely to be taken seriously than recommendations provided by co-workers who perform an internal audit.


In addition, they can provide education to coding staff or quality review staff and providers in regard to documentation. An outside audit firm can also aid with policies, procedures, training, and support.


In the end, even if your organization can conduct claim audits internally, an external examination of claim management processes is still beneficial and should be included in every healthcare organization, medical practices, FQHC and clinics as a compliance plan.

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