Scope of Medical Chart Audit

Overview

The primary purpose of a medical chart audit is to ensure that the charges appearing on a detailed, itemized hospital bill are accurate. This involves verifying that all billed charges correspond to actual services rendered to the patient, confirming that such services were ordered by the physician, and ensuring they are consistent with established hospital standards, nursing protocols, and procedures.

Nurse Audit Review

A Nurse Audit Review is an essential process aimed at validating the accuracy of facility and surgery billing. This review is particularly important because medical bills can be highly complex and involve significant financial amounts. By leveraging a nurse’s clinical expertise and detailed analysis, the review can reveal inappropriate charges and services that might otherwise go unnoticed. The Nurse Audit Review should be conducted for bills that exceed certain thresholds, determined by their dollar amount, bill type, or complexity.

Limits of Automated Bill Review

Bill review extends beyond simply examining medical bills through state fee schedules, Usual, Customary and Reasonable (UCR) databases, or applying PPO discounts. When it comes to complex bills—such as those for high-level procedures, surgeries, or hospitalizations—there is currently no software or automated system capable of accurately re-pricing these cases. In fact, hospitals and healthcare organizations should avoid processing such bills automatically because of the risk of inaccuracies.

The Role of Skilled Auditors

Complex medical bills require the expertise of experienced bill review auditors, who have the ability to read, interpret, compare, and correlate the relative value of charges. Their skills are critical for recovering lost revenue by ensuring that all charges are fully documented, accurate, and maintain the highest standards of integrity.

Benefits of Outsourcing

Thorough analysis of surgery reports and other supporting documents for complex bills demands time and specialized knowledge. If an organization does not have enough skilled nurse auditors on staff, it is generally more cost-effective to outsource the entire bill review process—or at least the review of complex, high-value bills—to an external agency. This approach helps organizations follow proper procedures, ensure timely and accurate billing and documentation, recover lost revenue, and maintain compliance with medical chart auditing standards.

Julie Doumad RN, BSN, CCFA, CMAS

Director of Audit Services

(American Healthcare Audit Professionals, Inc.)