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What is a Medical Auditor?

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  • Written By: Mary McMahon
  • Edited By: C. Wilborn
  • Last Modified Date: 26 November 2016
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A medical auditor is a person who reviews medical records and billing data to confirm that bills were issued appropriately. Medical auditors improve quality and billing accuracy and help to catch billing mistakes that can lead to underbilling and other problems. People can become medical auditors by taking training classes in medical billing and coding. Pursuing certification through a professional organization is recommended in some areas, as it can increase employability.

There are several reasons why an audit may be recommended. A medical auditor could be part of a quality improvement team working to identify the strengths and weaknesses of a given facility, an internal employee who randomly selects things for review to maintain quality, or an employee of a government agency or insurance company who verifies billing information. The work assigned to a medical auditor is confidential in nature as it involves personal patient records, and medical auditors must observe strict ethical practices while they work.

The medical auditor compares a billing record with a patient's chart. If there are irregularities, such as billing codes for things not recorded in the chart or entries in the chart for procedures that were not billed, the auditor flags them. The auditor also looks to determine whether or not appropriate billing codes are being used for various procedures, office visits, consultations, and tests.

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A medical audit may not uncover any issues. It may also show that there are problems with the billing, and the auditor can determine whether these are random or systemic. Medical auditors can uncover things like fraud, where doctors bill for procedures never performed and pocket the money, as well as unclear staff communication that leads to entering incorrect billing codes for medical procedures. This can save money for insurance companies and government benefits plans in addition to improving efficiency in medical offices.

Medical record review is usually conducted in a controlled office environment. A medical auditor may be required to pass a background check in order to work, due to concerns and potential information compromises that could lead to identity theft or public disclosure of private medical information. This work requires an eye for detail and the ability to pore over extensive documents to seek out irregularities. Rates of pay vary, depending on where a medical auditor works, and benefits such as healthcare may or may not be available; auditors who work for clinics and hospitals may receive healthcare as part of their compensation package.

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JaneAir
Post 2

@strawCake - It is true, medical billing errors do sometimes happen. Medical billers and coders are human and sometimes they make mistakes.

This is why I urge everyone I know to really read over their insurance plans and pay close attention to what they're being billed for. A lot of consumers are too intimidated to question their medical bills but you shouldn't be. You pay for your insurance plan and that in turn pays your doctor. Everyone deserves to be billed for the correct amount.

I do think hiring a medical chart auditor to come in and look things over every now and then is a good idea for medical facilities. If fraud is being committed or mistakes are unknowingly being made they need to be found and corrected for everyones benefit.

strawCake
Post 1

It's great that a medical record audit can save money for insurance companies and the government but what about the patients? I'm sure patients being billed incorrectly results in extra charges for the patient more often than it does the doctor losing money.

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