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What is Medical Chart Auditing?

It never seems to amaze me the various definitions of a medical chart auditor. An auditor must be independent and at the same time a leader. The auditor is sometimes seen in a negative light that we are there to find fault instead of there to proactively identify, not unlike, preventative medicine approach to billing. The auditor is involved in all revenue generating departments within a hospital and has a wealth of information to share with department directors and the responsibility to teach compliance and Charge Description Master (CDM) responsibilities to the departments affected is essential to the position. In defending Hospital’s billed charges, an auditor must gather, clarify, obtain policies and procedures, and analyze the standard of care and billing practiced sometimes up to five years old from the patients discharge date. Persistence in follow up for the detailed information to support the charge is never ending. There is always the “Agree to disagree” but it should be noted that the contractual agreements MUST be considered and interpreted clearly by the facility and insurance auditor in the defense audit. So, add another responsibility to their repertoire. Another issue seems to be that many care providers view this process as low priority clerical function, this irrational conclusion may result in payer denials and Medicare inquires which may result in expensive penalties due to inaccurate billing.


An Auditor’s Ever Evolving Position


Auditor in the medical realm is an evolved position that incorporates nursing analysis, facility including inpatient and outpatient billing knowledge, quality risk management concerns as well as compliance knowledge base. A completely objective analysis is essential in this medical business. An auditor has different responsibilities facility wide as does the insurance auditor has in their realm but the audit should be conducted in the same manner the ultimate goal is a clean bill no matter what alliances you feel towards your employer. From a nurse’s perspective, keeping the clinical focus of the course of treatment and incorporating to the billing process is a daunting task and can become overwhelming without a focus. Prioritizing department by department does make the audit more manageable. Verifying all results are documented and ordered is essential to support the charges.


Communicating Within Departments

Teaching is mandatory function of the chart auditor. Examples include policy and procedure development and ensuring that the facility is in compliance with its established policies. The Medical Auditor shall communicate audit outcome statistics and identified problems to administrative management and conduct the monthly meeting of the Hospital Chart Audit Committee. All responsible departments involved with revenues affected by audit outcomes are paramount to the audit resolve for issues identified during the audit committee meeting. It is essential that the Chief Financial Officer and Department Directors attend these meetings to support the importance of the audit functions in the facility not to mention the tremendous growth and understanding of the CDM for the departments addressed and that there are consequences for repeated unresolved concerns identified by audit results.


Conclusion

As a Certified Medical Audit Specialist and Clinical Certified Financial Auditor, I encourage auditors to develop and educate themselves and share your knowledge and focus to complete the chart audit tasks not taking on so many duties as to be unable to complete audits in which no other employee has the training to complete. In conclusion, Auditing takes endurance knowledge people skills and determination for doing the right thing the right way, in short the next time you see your auditor smile and appreciate the work they contribute to your organization that rarely is recognized.


Julie Doumad RN, BSN, CCFA, CMAS

Director of Audit Services

American Healthcare Audit Professionals, Inc.

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