1. Define the audit objective and period
Choose the service lines, payers, providers, locations, claim dates and financial questions the review must answer. A defined scope keeps the audit measurable and prevents isolated findings from being mistaken for system-wide problems.
2. Confirm provider and payer readiness
Review enrollment status, effective dates, group affiliations, service locations, taxonomy and payer participation. A technically valid code can still be denied when the rendering provider or billing arrangement is not eligible for the service.
3. Trace claims from charge to adjudication
Compare documentation, charge capture, claim creation, clearinghouse acceptance, payer adjudication and account status. Separate front-end rejections from payer denials because they require different corrective actions.
4. Review denials, underpayments and aging A/R
Group issues by payer, provider, service, denial reason, dollar value, filing limit and root cause. Look for repeated patterns rather than reviewing every unresolved claim as an unrelated event.
5. Reconcile payments and adjustments
Match ERA or EOB detail to confirmed deposits, contractual adjustments, patient responsibility, recoupments, credits and unapplied cash. Payment posting accuracy affects both financial reporting and follow-up decisions.
6. Assign corrective actions
Document the issue, financial exposure, responsible owner, due date and success measure. The audit becomes valuable when findings lead to operational change and follow-up verification.
Turn the findings into clear next actions.
Request a confidential business conversation. Do not submit PHI through the public form.