Provider Bill Audit
Hospital Bill Audit
During a hospital bill audit, clinical staff conduct onsite reviews of a member's medical charts and interview provider staff to validate any overpayments. The success of our hospital bill audit program is based upon our reputation of providing a fair and accurate audit and protecting our clients' relationships with their providers.
Focus of the Hospital Bill Audit:
- Service is consistent with diagnosis and billing is consistent with services
- There has been no unbundling of services, diagnosis upcoding, or billing maximization
- Services rendered were prescribed by the physician and the doctor's notes were signed
- Standardized billing and payment policies were used
Credit Balance Audit
During a credit balance audit, staff conduct an onsite review of a provider's financial records and systems and has discussions with the provider's staff. The credit balance audit ensures that improper or excess payments resulting from patient billing and claims processing errors are identified and refunded.