If you’ve been in the game a while, then you’ve heard tons of terminology over the years. It can be tough to remember everything while you’re holding all your medical knowledge, too, but when it comes to medical auditing and compliance terms, you need to know your stuff.
When you work with our team at Medical Auditing Solutions, you’ve got a compliance companion. You have patients to help, so we help you spend more time on them and less time in a claim portal trying to figure things out. From quality compliance training to assistance before or during an audit, our team works side-by-side with providers of all shapes and sizes. So, when you need to brush up on your payer language, or if you’ve got a question about code changes, let’s talk about it.
Staying up to date with the latest is easier with Medical Auditing Solutions. Take some time today to talk to our team about your office’s needs.
Understanding Upcoding And Fraudulent Billing
One of the most essential concepts to comprehend as a compliant office is upcoding. This is the practice of billing for a higher code than is commonly used, and it’s becoming more easily caught through technology. Now that payers are using AI to check claims, they can spot outliers in an instant.
Modifiers Can Create Office Confusion
If you’re misusing codes, it could come back to haunt you. Modifiers can be a reason for that; they often cause confusion among staff. But it doesn’t matter whether the mistake was unintentional or not, payers want to pay out appropriate claims. Modifiers -25 and -59 are some of the riskiest, so talk to our team about ways to use them well.
An oversimplified explanation is that Modifier 25 is appended to an Evaluation & Management Visit, with Modifier 59 appended to the second of duplicate CPT codes, For instance, it may be the CPT is RT and LT but needs to be billed separately on the same day.
Bundled Payments Are Often An Audit Trigger
It might seem simpler to move from a fee-for-service model to bundled payments, but payers make that tougher. Since their fraud detection software inspects claims line by line, they want to know what’s going on in detail. That means that bundled payments can often act as an audit trigger.
Bundled payments incentivize provider efficiency, but they require strict compliance. For example, you cannot cherry-pick healthier patients for a service to keep your costs low. Our team can help you to understand how to handle bundled payments, if that’s the path you’ve chosen.
Denial Prevention Is A Must In 2026
With AI tools at payers’ disposal, denials are increasing. Before claims are even processed, they are run through a barrage of tests to make sure that they meet compliance. We help teams focus on denial prevention, not just management.
Stay Compliant With Medical Auditing Solutions
It’s tough to navigate every claim perfectly every single time. To find out how we help offices do just that, call Medical Auditing Solutions at (972) 459-1508 today.