An internal audit can help your practice identify any errors in your billing, coding or medical records, and can help you discover whether you’re violating any regulatory requirements. These audits can be prospective (where you review claims prior to submitting them) or retrospective (when you review claims that were paid).

Whichever you choose, remember that an internal audit can be time-consuming, so it’s important to do yours right the first time. Check these five tips to succeed.

1. Review Policies and Procedures

Check whether your practice has clear, up-to-date written policies, and that your staffers are trained on compliance with all of those policies. Ensure you have internal controls in place to prevent errors, and have your insurer policies (such as coverage determinations) and code books on hand.

2. Include All Staff Members

Everyone at your practice should be involved in your internal audit, because everyone has at least some part in the claims process. Providers handle documentation, your front desk team gathers insurance information, billers submit claims and coders choose the codes.

3. Check the Claims

CMS lists the following as specifics to look for when self-auditing claims:

• Evidence of good data integrity, like a general lack of blanks, zeroes, unreasonable values, edits, and duplicate entries
• Service dates, reason for each visit, and physician’s orders for services, as required
• Appropriate history, past and present diagnoses, risk factors, conditions limiting treatment, medications, and allergies with correct spelling and use of terminologies
• Full information on labs, tests, exams, and X-rays with reasons, results, and good copies
• Progress, treatment plans, responses and changes, medication dosage, timing and usage, anesthesia, patient and family education, and any suspicious or “watch” areas
• Patient communications and information on missed appointments
• Legible contents, dated and signed with appropriate indication of valid credentials, and the correct administration and initialing of any additions, erasures, deletions, or alterations
• Reasonable and appropriate patterns and relationships among vendor, provider, and beneficiary demographic and geographic characteristics

4. Document the Audit

During the internal audit, you’ll review medical records, billing and coding practices, claims, documentation and payer reimbursement (if the audit is retrospective). Look for correct use of coding and detailed patient documentation as you perform the audit. Then be sure to document the date of the audit, which records were reviewed, findings, and who participated.

5. Handle Overpayments Properly

If you perform a retrospective audit and find that one or more payers reimbursed you too much money, you must refund the money.

CMS states that overpayment occurs when “CMS pays a provider more than the amount due and payable according to existing laws and regulations.”

Many entities, such as CMS and the OIG, provide an option for self-disclosure if a potential violation is uncovered during an internal audit. However, not every error found in an internal audit means fraud is present. If you’re unsure whether you must self-disclose any issues, meet with your practice’s attorney and ask.