Medical Billing AuditServices
Coding validation and compliance checks using NCCI edits and CMS guidelines. Expert medical billing audit services to ensure accuracy and compliance.
Medical billing audits — whether internal compliance reviews or external payer audits — can expose serious revenue and compliance risks for your practice. MedSure's certified medical auditors conduct proactive internal audits to identify overcoding, undercoding, and documentation gaps before a payer finds them. We also support your practice through external RAC, MAC, and OIG audit responses with complete documentation and appeals.
Medical Billing Audit Solutions
Specialized medical billing audit services designed to streamline your workflow.
Key Features
- Coding validation and accuracy checks
- NCCI edit compliance verification
- CMS guideline compliance review
- Documentation review and validation
- Compliance risk assessment
- Audit report and recommendations
Benefits
- Identify and correct coding errors
- Reduce compliance risks
- Improve claim accuracy
- Prevent audit penalties
- Ensure regulatory compliance
- Comprehensive audit reporting
How It Works
Our proven process delivers results for your practice.
Audit Scope & Sample Selection
We define the audit scope based on your risk profile: high-volume CPT codes, E/M level distribution, recently changed coding patterns, or specific payer focus areas. We select a statistically valid sample of claims for review.
Documentation & Coding Review
Our CPC-certified auditors review selected encounters in detail — comparing the clinical documentation against the codes billed. We check E/M level support, diagnosis code specificity, modifier usage, bundling compliance, and medical necessity documentation.
Findings Report & Risk Assessment
Audit findings are compiled into a detailed report categorizing issues by type and severity. We calculate error rates, estimated overpayment/underpayment amounts, and assign risk levels to each finding to help you prioritize corrective action.
Corrective Action & Education
We develop a corrective action plan addressing each audit finding. Provider education sessions address documentation improvement opportunities. We conduct follow-up audits 90 days after implementation to verify that error rates have improved.
Frequently Asked Questions
Get answers about our Medical Billing Audit services.
What is the difference between a RAC audit and a MAC audit?
RAC (Recovery Audit Contractors) audits are post-payment reviews conducted by CMS contractors looking for Medicare overpayments. MAC (Medicare Administrative Contractor) audits include pre-payment reviews of specific claim types. Both can result in payment recoupment — proactive internal audits help you identify and correct issues before either type of external review.
How often should a medical practice conduct internal coding audits?
CMS and the OIG recommend annual coding audits at minimum for most practices. High-risk specialties (orthopedics, cardiology, oncology) and practices with high Medicare volume should consider semi-annual audits. After implementing corrective actions, a follow-up audit within 90 days confirms effectiveness.
What happens if a payer audit finds overpayments?
If overpayments are identified, payers will request repayment — sometimes with interest and penalties. MedSure assists with audit responses, reviewing each finding for accuracy, and filing appeals for findings we believe are incorrect. We also help structure repayment arrangements when legitimate overpayments exist.
Can you help if we receive a pre-payment review or ADR?
Yes. Additional Documentation Requests (ADRs) require responding within strict timelines — typically 45 days for Medicare. We compile complete medical record documentation, prepare a thorough response letter, and track the case through resolution. Proper ADR responses prevent automatic denials.
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