Routine medical record audits serve three important functions:

  1. They provide a check-up on documentation and billing patterns. Problematic compliance can be identified and corrected through training before a real audit happens and a large refund is demanded.
  2. They can satisfy the recommendations and requirements of payers
  3. They can identify areas of revenue based on medically necessary care that are not being provided by the doctor.

Auditing medical records is an essential part of any Compliance Program and overall, an excellent idea for any practice.  While there are no national legal mandates for voluntary audits, the CMS recommendations include a minimum of ten (10) patient encounters per provider per year. Other payers are starting to recommend or even require evidence of medical record audits for credentialing. The audits can be conducted internally, or you can contract with a professional auditing service. It is a good suggestion to have an outside or professional audit conducted initially with the implementation of a Compliance Program. It is unlikely that problems will be found if the internal auditor is not highly knowledgeable and trained in the law and audit process. Follow-up audits can be conducted annually and performed internally by the practice providers. Repeat professional audits are recommended at least every five years.

The Consequences of Non-Compliance

The laws surrounding billing, coding, and medical documentation are not only binding and enforced by law, but they also change regularly and often without warning.  As such, there are steep consequences to not adhering to these regulations — consequences for which ignorance of the laws is no excuse. This was just recently confirmed by actions of the United States Supreme Court, stating claims that regulations were unknown or too complex did not even pass the court’s “laugh test”.  The penalties for providing care that is not medically necessary, not according to preferred practice patterns and payer rules and not accurately and completely documented can include heavy fines and potential removal from the provider panel. This is true for medical and vision plans. Every year, Federal and State agencies levy millions of dollars in fines that could have been avoided by trusting the experts to look over your charts.

Choose the Right Audit for Your Practice

PCS offers two different audit services to serve the unique needs of your practice: Comprehensive Chart Audit Service and Fraud & Abuse (F&A) Chart Audit Service.

Our Comprehensive Chart Audit goes beyond medical records to meticulously analyze billing and coding practices as well. 20 charts per provider is recommended but customizable packages are available for larger offices or practices with multiple locations. Once the audit is completed, you’ll receive a thorough report of any documentation, billing, and coding issues identified as well as insight on the financial impact of any lost revenue due to poor documentation, coding errors and potentially medically necessary care not rendered. The cost is $1500 per 20 patient encounters.

Our Basic Audit meets the minimum audit recommendations from CMS. Much like a real medical record audit, billed services are compared against the medical record documentation but only to determine if the services should be paid or not. This audit is priced at $750 per 10 patient encounters.

The Comprehensive Chart Audit is the best way to ensure both maximum compliance and maximum reimbursement. While CMS allows providers to “self-audit” their records, PCS highly recommends a professional audit initially and then at least once every 3-5 years. With proper auditing, you can operate with peace of mind, be more confident in your billing practices and focus on providing excellent care to your patients.  Training audits are the best way to ensure your practice will be ready and safe when a real auditor comes around. If you have questions or would like our help reach out at