Medical Billing Audit Checklist: 20 Things to Check Before You Lose More Revenue

By MedicureMD Billing Team. Reviewed by an AAPC-certified coder.

A medical billing audit checklist helps you find where your practice is losing money: claims that were never sent, denials nobody followed up and payments that came in lower than they should. This checklist has 20 checks in five groups. You can run it yourself in an afternoon, or hand it to us and we will do it for you.

A medical billing audit is a review of your claims from the visit to the payment. It looks at whether services were coded correctly, whether claims went out clean, whether denials were worked and whether you were paid what the payer owed you.

Most practices only look at their billing when cash flow drops. Running a medical billing audit checklist every quarter catches small problems before they turn into months of lost revenue.

1. Pull a report of your last three months of claims from your billing system.
2. Pick a sample of claims across different payers, providers and visit types.
3. Go through each check below and mark it pass or fail.
4. Write down every fail with the claim number. Patterns show up quickly.
5. Fix the cause, not just the claim, and run the checklist again next quarter.

1. Insurance eligibility is checked before every visit, not after.
2. Patient name, date of birth and insurance details match the insurance card.
3. Prior authorization is obtained when the payer requires it.
4. Copays and known deductibles are collected at the visit.

5. The visit level (E/M code) is supported by the documentation in the chart.
6. Diagnosis codes are specific and support the procedure billed.
7. Modifiers are used correctly and only when needed.
8. Every service is charged. Nothing is missed between the exam room and the claim.

Coding errors are among the hardest to see from the outside. If your team does not have a certified coder, consider a review of your coding by an AAPC-certified coder.

9. Claims are sent within a day or two of the visit.
10. Your clean claim rate (claims accepted on the first try) is tracked every month.
11. Rejected claims are fixed and resent the same day.
12. Timely filing deadlines are known for every payer, and no claim is close to missing one.

13. Denials are tracked by payer and by reason, so repeat problems show up.
14. Denied claims are appealed before the payer’s deadline.
15. Days in accounts receivable (A/R) are tracked every month.
16. The aging report is checked, and claims older than 90 days are being worked.

17. Payments are compared with your contracted rates, so underpayments are caught.
18. Payments are posted accurately and quickly.
19. Patient balances are billed and followed up, not left on the books.
20. Provider enrollment and credentialing are current, and HIPAA safeguards are in place.

Check 20 matters more than it looks. If a provider’s payer enrollment lapses, claims can be denied until it is fixed. Our credentialing services keep track of this.

These are common rules of thumb. The right targets vary by specialty and payer mix.

If your numbers are far from these, that is a sign to look closer at coding, front-office checks or follow-up on denials.

Running this checklist yourself works if you have someone with the time and the billing knowledge. If not, our free medical billing audit covers the same ground. We review your claims, denials, accounts receivable and coding, and send you a written report within 24 to 48 hours.

If you decide to hand the work off, see how our medical billing services and revenue cycle management work.

Many practices run one every quarter. If you are seeing a rise in denials or slow payments, run one right away.

Someone who knows coding and billing rules, ideally a certified coder who does not work on your daily claims. Practices without that person often use an outside company.

Pick a sample that covers different payers, providers and visit types. The sample should be large enough to show patterns, not just one-off errors.

We review your claims, denials, accounts receivable and coding, then send you a written report within 24 to 48 hours.