Billing and coding audits
An audit answers two questions at once: where are you exposed, and where are you leaving money behind. Usually both are true.
The problem this fixes
Practices under-bill and over-expose themselves at the same time. Providers who fear audits code conservatively and lose revenue on every encounter. Elsewhere in the same practice, a modifier is being applied incorrectly in a way that would not survive a payer review.
Neither problem is visible from the inside, because the people doing the coding are the people who'd have to catch it.
The timing usually makes it worse. Practices tend to audit after something has gone wrong — a records request, a payer review, a denial pattern nobody can explain — which is the most expensive moment to discover a pattern that has been running for years. A baseline audit at the start of an engagement costs a fraction of a retrospective one prompted by a payer.
What goes wrong when this is done badly
Four failure modes we see repeatedly, and each one is a process problem rather than an effort problem.
Auditing only for over-coding
An audit that looks for compliance exposure and not for missed revenue tells a practice half of what it needs and leaves the undercoding in place. Both directions cost money.
Sampling too small to mean anything
Five charts per provider produce an anecdote. A finding that cannot support a conclusion cannot support a remediation plan either.
A report with no education attached
Findings delivered as a document change nothing. The providers whose documentation caused the findings need to hear what specifically to do differently.
Auditing once and never again
A baseline with no follow-up cannot show whether anything improved. The second audit is where the value is, because it measures the change.
What's included
Every item below is a deliverable, not a capability statement.
Documentation-to-code review
Against payer and CMS guidelines.
E/M level validation
Under current MDM and time-based rules.
Modifier usage review
Including the modifiers most often misapplied in your specialty.
NCCI edit and MUE compliance testing
Applied across the sample.
Medical necessity and LCD/NCD alignment
Diagnosis-to-procedure support checked against policy.
Under-coding and missed-charge identification
Revenue you earned but never billed.
Contractual underpayment detection
Against your own fee schedules.
Compliance risk scoring
Ranked so you know what to fix first.
Written findings report
With prioritised recommendations.
Provider-level education session
Live, on the findings that concern each provider.
How it works
- 1 Scope We agree the audit type, the providers in scope, and the sample size.
- 2 Sample Charts pulled — [CLIENT INPUT — typically a statistically valid sample per provider].
- 3 Review Documentation read against the code billed, by a certified auditor.
- 4 Report Accuracy rate, financial impact in both directions, and a risk ranking.
- 5 Education A live session with your providers on what the findings mean for their documentation.
Audit types
| Type | When it runs | What it finds |
|---|---|---|
| Retrospective | On claims already submitted | Historical undercoding, compliance exposure, recoverable underpayments |
| Prospective (pre-bill) | Before submission | Errors caught before they become denials or liabilities |
| Focused | On a specific code, provider, or denial pattern | Root cause of a recurring problem |
| Baseline | At onboarding | A starting picture of accuracy and revenue capture |
What you get back
- A written report showing accuracy rate by provider
- Financial impact of errors in both directions — under-coded and over-coded
- Compliance risk ranking with a prioritised remediation plan
- A live education session with your providers
Who this is for
- Practices that have never audited their own coding
- Practices that suspect their current billing company is underperforming
- Practices with a recurring denial pattern they cannot explain
- Practices onboarding new providers or a new specialty line
What we measure
The numbers this service actually moves. You see all of them weekly, in your own system, with the benchmark alongside.
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Documentation-to-code accuracy The share of sampled encounters where the code billed is supported by the record, reported per provider rather than as a practice average.
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Financial impact in both directions Under-coded revenue that was earned and never billed, alongside over-coded revenue that carries repayment exposure. Reporting only one of them is how audits become sales tools.
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Compliance risk ranking Findings ordered by likelihood and consequence, so remediation starts with the thing that would actually cost you rather than the thing that is easiest to fix.
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Repeat findings at the next audit Whether the education worked. An audit that finds the same errors a year later did not change anything, and that is worth knowing.
Benchmark ranges are sourced from MGMA and HFMA MAP Keys. MedBil's own figures are published only with a stated measurement window, per specification section 12.7.
Where this matters most
The specialties where this part of the cycle carries the most risk and the most recoverable revenue.
Start with your own numbers
We measure your denial rate, A/R ageing and net collection rate against industry benchmarks before you commit to anything. You keep the analysis either way.
- 90 days of claims data, no patient identifiers needed
- A written analysis, not a sales deck
- No contract, and no obligation to proceed
- Client results published with a stated measurement window, once available
Questions about medical billing & coding audits
Will an audit expose me to liability?
Internal audits are a recognised element of a compliance programme. The OIG publishes compliance guidance for both physician practices and third-party billing companies that treats self-auditing as best practice.
How many charts do you review?
[CLIENT INPUT — typically a statistically valid sample per provider]
Do you audit other billing companies' work?
Yes. This is a common request when a practice suspects underperformance.
How often should we audit?
At minimum annually, plus a focused audit whenever a denial pattern emerges.
Related
Where this connects to the rest of the cycle.
Eligibility & Benefits Verification
Coverage and benefits confirmed before the visit, not after the denial.
See eligibility verificationPrior Authorization Services
Auth requests submitted, tracked, and escalated so procedures aren't delayed.
See prior authorizationPatient Billing & Collections
Statements, payment plans, and patient support that doesn't damage the relationship.
See patient billing