Revenue Integrity Audits

Revenue Integrity Audits analyze the flow of charges from the point of order through to final third-party adjudication. These audits are an essential tool for visualizing the big picture with regard to charge processing and often identify additional opportunities which may otherwise go unnoticed. Even with a clean and compliant CDM, there are many other areas up and downstream that can have deficiencies leading to revenue loss, compliance risks, or both.

An IRI consultant will review a selection of encounters provided by your facility. This review may be performed on-site, or remotely. You choose the number of encounters you would like reviewed and the scope of clinical service areas (e.g., 20 cardiac catheterization encounters, 50 encounters from various clinical areas, etc.). The following elements are examined for each encounter: 

• Physician orders
• Medical record documentation
• Itemized patient charges
• UB04/HCFA claim form(s)
• Third-party remittance advice

Each encounter is examined to determine whether: 

• All services have valid physician orders (including proper dates/times/signatures, if applicable)
• All services which are charged for are supported by documentation
• All services which are documented have been charged for
• Charges have been reported correctly on claim forms in accordance with CMS and other requirements
• Services have been properly reimbursed by third-party insurer(s)

A written report and detailed line-by-line results are provided which identify any deficiencies in orders, documentation, charge capture, or reimbursement. Revenue Integrity Audits may be provided as a stand-alone service, or as an added component of a Charge Master Review. Please contact us for more information.