Medical Consulting And Auditing Services In New York (NY)


In order to run a successful medical practice, opting for medical consulting and auditing services from a medical billing company in NY is the best idea! Now you would be wondering what medical auditing and consulting services are. Basically, you can define medical auditing as a system that assesses the performance within a healthcare organization. Consultation and auditing can be done on any medical care element.

The main components that most accurate medical billing and audit include are the ones that are involved in the reimbursement process. It is done in order to evaluate whether or not the practice complies with payer guidelines and State regulations. The consultation and auditing help in identifying errors as well as providing device solutions in order to eliminate them. This is why auditing and consultation services should be outsourced in order to ensure that the healthcare organization complies with the rules and regulations.

Outsourcing medical billing services from medical billing companies like UControl Billing will help with auditing and consultation.

Their medical billing specialist will:

  • Boost-up revenue cycle management
  • Make sure that appropriate revenue is captured
  • Review that patients are provided with quality care
  • Enlighten providers regarding documentation guidelines
  • Determine whether policies of the organization are current and effective
  • Safeguard against federal and payer audits, health plan denials, and malpractice litigation

Why Perform Medical Auditing and consultation?

It is essential for a medical practice to audit and consults when it comes to policies, coding accuracy, and procedures. Reviewing a practice makes sure that all its operations are efficient and clean. The vice president of Operations of Merem Healthcare Solution,  Lindsey Wingate, states that “Audits are performed not only to ensure compliance but to make sure there is no missed revenue for the provider.”

There are several reasons for medical auditing services. Auditing can help a medical practice in:

  • Recognize under coding
  • Recognize code overuse
  • Recognize bad unbundling habits
  • Recognize the use of incorrect codes
  • Identify opportunities for reimbursement
  • Identify inappropriate coding before being challenged
  • Let your coding staff know about areas of improvement
  • Help safeguard against fraudulent billing activities and claims

While discussing medical auditing and consultation services in NY, Wingate says the following “In my experience, it takes specialized and certified staff to know all the rules and regulations for billing different specialties. When performing an audit for practice, more often than not, I find that charges are being missed due to a lack of knowledge in CPT, AMA, and CMS guidelines.”

Some medical billing companies in NY provide these services, and outsourcing such services can be beneficial as no matter how well trained staff is, auditing and consultation are still necessary. Outsourcing medical billing services can help you in auditing as well as consultation.

What Are The Different Types Of Healthcare Audits?

The healthcare audits include two types of auditing:

  • Internal audits
  • External audits
  • The external audits are further divided into two types:
  • Government healthcare audits
  • Commercial healthcare audits

Government healthcare audits can be further divided into two types

  • Medicare audits
  • Medicaid audits

 Let us now explain the types and subtypes of medical auditing:

Internal auditing in healthcare

The auditing that takes place inside the healthcare practice is known as internal auditing. In this major type of auditing, the practice undertakes an internal review of its finances. There are plenty of reasons behind internal auditing. The main reason is to identify potential audit exposure as well as to address the issues that may cause an audit down the road.

The process of internal auditing begins when different subsets of claims are selected inside the organization in order to examine them from the viewpoint of compliance. For instance, a medical practice is worried that documentation is being coded incorrectly. To examine this, the internal auditors select a group of codes and review them for checking accuracy. In addition to that, preauthorization is another thing that can be audited by internal auditors. This helps a practice to ensure whether the staff is using correct preauthorization for specific types of care.

In case the auditors find numerous errors, the healthcare practice knows that they should have a team that should organize and check codes on internal paperwork. This is a tedious task, but it is important to avoid negative consequences. When you outsource from a medical billing company, it is their medical billing specialists’ duty to ensure that every code and other billing process are regulated in accordance with the regulations.

It is not necessary that all internal audits are related to finance. Some audits are related to the standard of patient care. The auditors examine if the patients are provided the care that falls in line with what is advised by the board of directors. Each and every component of a medical practice can be audited in order to search for improvement!

External auditing in healthcare

The external audits, as the name suggests, are the audits that are conducted by some outsider organization in order to examine a medical practice’s financial stability! The outsider organization is often a government or a commercial insurance company—the audit in order to ensure that even in the past, the hospital was paid correctly.

Government healthcare audits

In external auditing, the first auditors are government healthcare audits. On both a state and federal level, the government is responsible for providing a medical practice with reimbursement for healthcare services. They repay following the state and federal guidelines as well as on the type of assistance provided. In this type of audit, there are two main types.

In the first type of government healthcare audit, the auditors examine the Medicare claims and reimbursement. One of the biggest hospital payers is Medicare. They make up about 40% of the payor mix. This type of government healthcare audit is usually done by third-party recovery audit contractors or federal government employees.

Coming to the second type of government healthcare audit, this type of audit focuses on Medicaid. The audits for Medicaid are usually done by contractors and sometimes by government employees. The compulsion is that whoever audits must have complete knowledge of the laws of the state. This is because the laws of Medicaid differ from state to state.

The contractors are usually trained to audit staying within a specific state. Some are only specialized in auditing specific medical matters. The activities of Medicaid audits depend on numerous factors. The state’s Medicaid office employees audit contractors on and off, so practice should always be ready. Outsourcing medical billing services from medical billing companies in NY ensures that your practice is always ready for such audits!

Commercial insurance healthcare audits

Government healthcare audits may occur on and off; on the other hand, commercial insurance healthcare audits, especially the big one, are completely a different story. Commercial insurance healthcare audits occur on a regular basis.

When the contract between a hospital and an insurance company is made, they tend to negotiate about the reimbursement rates as well as decide upon the components that can be audited. The insurance company then audits claims based upon the agreed components.

Commercial insurance healthcare audits vary from government audits. This is because government audits are based on laws and regulations. On the other hand, commercial insurance healthcare audits can be negotiated between the hospital and insurance companies.

How Do Hospitals Handle Healthcare Audits?

As audits and denials are complex, they involve a lot of paperwork. It is, therefore, a tough and painstaking job as the documents are submitted to an outside agency. In order to be successful in auditing, one has to meet all the deadlines as well as ensure that all the file submissions are accurate.

The complexities imply that the team responsible for handling audits must be well-trained, efficient, and dedicated. Sometimes in order for faster workflows and a low rate of errors, medical practices opt for medical billing services from a third party. And without a doubt, outsourcing from medical billing companies in NY is a great idea! For best medical billing services, one must check out UControl Billing!

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