Internal monitoring of physician billing and coding

Physian practices should always be aware of any and all internal risks identified in the past that need to be monitored. Internal monitoring of some of the areas below can also help to identify potential billing and coding compliance risks:

– Medical record requests received by the practice from external entities (e.g., RAC, MAC, CERT, OIG, Medicaid Integrity Contractors, others). These can include routine additional documentation requests, prepayment reviews, postpayment audits, etc.

– Repeated denials for the same type of claim error may be considered submission of false claims.

– Benchmarking of billing patterns by physician, by specialty, and in comparison to other physicians within your system, or using outside data, such as CMS or other commercially available data can allow a practice to identify physicians who are outliers in comparison to their peers.

Internal monitoring can help a practice focus its auditing on the identified potential risk areas. No matter what size a practice you are, you need realize billing and codinig compliance risks can lurk anywhere. Just remember the key to any compliance activity is to:

1. Prevent

2. Detect

3. Correct