A “pre-billing audit,” wherein healthcare organizations would audit coding and billing and document improvement opportunities.

1. Pre-billing:A SafetyNet
By Carlos Arias,,MD,CPC
Imagine drivingonanarrow road betweentwomountains. Suddenly, rocksbegintumblingdown
aroundyou fromboth sides.Thatis, I believe,the feeling manyprovidersandhealthcare companies get
whena final decisionfromafederal orcivil court getspublishedonthe Office of InspectorGeneral(OIG)
website, knowingthatmore than75% of compliance issuesinhealthcare are relatedtocodingand
billingpractices.
A couple of yearsago,after lookingatour organization’scodingandbillingprocess,we decidedto puta
processinplace that we calleda “pre-billingaudit,”whereinwe wouldauditcodingandbillingand
documentimprovementopportunities.Atthe beginning,we encounteredalotof resistance from
physicians whowere claimingthatthey perceived acashflow impact.Theywere right.
We learnedthatwe didnothave the neededhumanresourcesandprocessesto file the claims ina
timelymanner. Itwaspainful. Ourbacklogcouldbe as longas twelve weeksata time,butwe
persevered.Topmanagementwasinvolved(the Boardof Directorswasengagedandguidingthe
process) -- we didnot wantto take any chances.Since then, ouraccuracy has increasedtoindustry
standardbenchmarksandcontinuouslyimproves.
Engagementof topmanagementwasourmost importantweapon. Ithelpedustoidentify our
bottleneck:lackof humanresources;training;and asystemtomonitor,evaluate andmeasure our
codingand billingprocess. We alsodiscoveredthat havinganinternal compliance coderteamisvery
helpful,asisanIT database or software.
Our definitionof the pre-billingprocessis, the actof auditingthe progressnotesbefore aclaimis
produced.Think of itas “gettingitright the firsttime.” Youdon’twant to have to re-code andre-bill the
progressnote--ifyouidentify additional informationafterthe bill goesout,it oftenraisesaredflagfrom
an auditingperspective.
For example,if acodersees informationthatismissing inthe record, thenhe or she shouldflagthe case
as containingadeficiencyanddelayfinalbillinguntil ananswerisobtainedfromthe provider. The same
goesfor a scenarioinwhichthe coderfeelsthatthere isenoughinformation inthe record fora higher
level of service. Ultimately,havingasecondlayerof coding auditorsfroma Quality Assurance
perspective isideal.
Overcodingorundercodingare badpracticesinthe codingand billing world.Of course youdon’twant
to holdthese casesforever,since thatimpactsthe revenuecycle.That’sanotherreasonforthe Medical
Company to create a seriesof policiesandproceduresthat:
 Describe the processandworkflow
 Outline exactlyhow longtoholda case before final codingandbilling
 Define whoisresponsibleforqueryfollow- up
 Describe exactlywhattodo(and whatthe nextstepis) if the providerdoesn’trespond
 Educate coders, billersandproviders
 Provide feedbacktoprovidersandcoders
 Describe how itwill monitor,evaluate andmeasure the accuracyof codersand billers

2. Facilitatingthe educationof evaluationandmanagementandICDcodingguidelinesforcoders and
providersisthe keytosuccess in thisprocess.Continuousinternal andexternal auditstocorroborate
codingaccuracy shouldbe part of the compliance program.Thissystemincludeslarge investmentsinIT
and Humanresources, butI believeitisalwaysworthit…It is,withoutdoubt,asafetynet.