The scope of medical chart audit is verifying that charges on the detailed itemized hospital bill are accurate and that charges represent services rendered to the patient, are ordered by the physician, and are based upon standard hospital practices and/or nursing protocols and procedures.
A Nurse Audit Review agenda is to validate facility and surgery billing accuracy. This process should be a vital part of any health organization. Due to the complexity and dollar size of certain types of medical bills, utilizing a nurse’s skilled analysis and hands-on evaluation can uncover inappropriate charges and services. The Nurse Audit Review needs to be applied to bills as determined by the thresholds set by the dollar volume or bill type and complexity.
Bill review is not just a basic process of reviewing medical bills based on state fee schedules, UCR databases, and applying PPO discounts. When dealing with complex bills such as high level, procedural, surgery and hospital bills, there is no software product or system that can automatically re-price these types of highly complex bills. The fact is hospitals and healthcare organizations should not want these types of bills to be processed automatically!
These types of bills require a skilled and experienced bill review auditor's ability to read, interpret, compare, and correlate relative value to assist in recovery of lost revenue through proper documentation and to insure and promote the accuracy and integrity of charges.
Analyzing and understanding surgery reports and other complex bill supporting documents requires time and expertise. Unless the organization has sufficient skilled and experienced nurse auditors on staff, then it is most likely more cost effective to outsource all bill review or at least their high-level bills to an outside agency to assist your organization to ensure that appropriate procedures are being followed for timely and accurate charges and record documentation and assist in recovery of lost revenue and maintaining compliance with Medical Chart Auditing.
Julie Doumad RN, BSN, CMAS
Director of Audit Services