Innovative training Academy

Dr.abdelkreem omar
Resubmission supervisor at Hay-elgamma hospital
(HJH)
Claim auditing at med-right for medical services
Abdelkreem.omr@msa.edu.eg
 Claims

Definition Model

Types Example
Definition of the claim
It Is paper or electronic document that provided from
insurance company to the provider for filling the insured data.
• all insured claims for specific period called batch.
• Transmittal is a group of batches
Claims contain
Insured data-effective date-patient diagnosis –applied services
–treatment doctor name –provider signature.
 Types of claims
In-patient

Vision dental

Out-
patient

Physiother scan
Pharmacy apy Lab
1)Consultation
2) X-ray
3)Labs
4) Pharmacy
 Medical auditing
• What Is Medical Auditing?
• Medical auditing is a systematic or manual assessment of performance within a
healthcare organization.
• identifying errors and devising remedial actions to eliminate them, the medical audit
serves a vital role in a healthcare organization’s compliance plan.
• Medical audits provide a mechanism to:
• Review quality of care provided to patients.
• Educate providers on documentation guidelines.
• Determine if organizational policies are current and effective.
• Optimize revenue cycle management.
• Defend against federal and payer audits, malpractice litigation, and health plan
denials
 What Medical Auditing do ??
• Make sure that services are withdrawn from the right benefits example
female pregnant patient presented by vomiting and received u/s
abdomen and dumpy tab??? .what is the benefit for these services ??

• Medical auditing for the needed documentation for processing the

claims.
• Make sure that data of insured are right data.
• Make sure the diagnosis are covered diagnosis according to the policy
• Make sure that services are billed according to the pricelist.
• Make sure that services are medically indicated to avoid deduction
• Make sure the right signature of the patient
• Modifying billing and coding errors.
• prevent incorrect coding from being repeated to prevent CCHI or any
federal organization invitation.
• Discovering overpayments and protecting against false claims liability

• Every medical coder should learn how to conduct a medical coding

audit in view of its potential value to their employer (and their coding
career). Fortunately, the audit process is easy to understand when
broken down into its component parts.
 Methods of auditing

1.A prospective audit helps identify and correct problems before sending claims to the
payer. In a prospective audit, you review the documentation along with the codes that
would have been billed to the payer. This allows for inconsistencies to be identified but
typically delays the billing process.
2.A retrospective audit is a post-payment audit to evaluate whether services that were
previously reported to a carrier were reported appropriately and consistent with the
carrier’s binding rules. The auditor reviews the documentation, claim forms, and
sometimes the explanation of benefits (EOBs) to ensure proper medical billing.
Each medical practice must determine which type of audit method will work for its
environment. It’s also important to note that errors identified in the retrospective audit
must be resolved through corrected claims, refunds to the payer, and possible self-
disclosure.
 Medical Audit Checklist

1.Is the patient still active and eligible for the date of service (DOS) on the claim?

2.Do the claim demographics and data specifically match the medical records?
(for instance, the same patient name and birth date, DOS, place of service [POS], etc.)

3.Is this the only claim submitted by the provider? Review the patient’s claims history
for a previously denied or paid claim from this same provider for the same DOS, codes,
and charges. If there is a previously paid claim, what codes (claim lines) were paid and
what were denied?
If there are claim lines denied, what was the reason?
What records were submitted with the previous claim? Are they the same or were
additional records sent?
Is this a duplicate claim submitted by the provider?
Is the provider split-billing services performed on one DOS onto more than one claim?
4.Is the billing provider the rendering provider? And is this a licensed
provider?
5.Was the required documentation submitted?
6.Does the medical record align with the CPT® and HCPCS Level II
codes on the claim? Look for up coding, miscoding, unlisted codes, and
unbundling of services.
7.Are modifiers clearly supported and used appropriately in the medical
records? For example, is there enough notation to support modifier
25 Significant, separately identifiable evaluation and management
service by the same physician or other qualified health care professional
on the same day of the procedure or other service performed? Are
modifiers 26 Professional component and TC Technical
component supported by the billing provider and the POS?
8.Are the number of units billed correctly? Does the claim report 1 unit
or multiple units for the code, as appropriate?
9.Do the ICD-10-CM codes reported on the claim align with the medical
documentation? And are the diagnoses coded to the utmost specificity
(based on documentation)?
10.If the claim is billing for radiology, is there an interpretation of the
report included? An interpretation is required when a provider is billing
the professional component only or billing a global service (both
technical and professional components).
11.If the claim contains billing for durable medical equipment, is there a
valid, complete physician order or prescription included in the medical
record?
12.At the end of the medical record, is the documentation authenticated
by the rendering provider? Are the rendering provider signature
requirements met? What type of a signature is listed?
Last reviewed on March 5, 2021.
 Types of rejection

1)Technical rejection
it is the type of rejection that responsible reject the wrong
amount of the following:
Medical rejection

It is type of rejection that responsible to reject the services which is

medically unjustified or have no indications or missing approval to be
taken.
Reject also uncovered diseases.
Reject the services which is out contractual services
Reject the exclusion.
Reject the services which is out of pricelist.
Reject the services which is not medically necessary
 Uncovered disease
• Schizophrenia
• Mode disorder
• Depression
• phobia all panic disorder
• Manic disorder
• Neurasthenia
• Mental retardation
• Eating disorder
• Non organic sleep disorder
• Behavioral and emotional disorder
• Telogen effluvium and all psychiatric disorders.
• Acne
• Alopecia
• Hair loss
• Hearing aids
• Hirsutism
• Hyperpigmentation
• All congenital diseases as (congenital heart defects-hypoplasia
– gastroschisis…….ex)
• family planning services (oral contraception , non oral
contraception…)
• Sexual dysfunction
Genetic disorders
• Sexually transmitted diseases (STDs)
• Chlamydia.
• Genital herpes
• Gonorrhea
• HIV/AIDS
• HPV
• Pubic lice
• Syphilis
• Trichomonas's
Rejection reasons