e-MDs Billing Tip: What Is A Basic Billing Audit?

e-MDs Billing Tip: What is a basic billing audit?



We are often approached by e-MDs practices that want a tangible way to measure the success of their current billing staff (whether it is in house or outsourced).  Some common questions include:  How do I know if my biller is doing a good job?  Are we writing off the things we should be?  Are my billers being efficient? What is our patient collections process?  Is our documentation substantial?  Other times, there may be hints of misconduct and the practice wants a third party to come in and analyze their billing workflow. Whatever the reason, Solor provides a “Basic Billing Audit” to help answer all of those questions.  We have posted a sample audit below.  You will get a feel of the findings and the examples that are used to substantiate the findings that are discovered (in blue below).


Smith Generic Practice Audit Findings

Prepared by: Solor, Inc.


Claims Editing:


  • TriZetto EDI Clearinghouse Issues
  • The Claims Submission Dashboard has several noticeable problems:
  • Some claims have been corrected but not removed from the dashboard.
  • This leads to a corrections process which would be complicated and inefficient, but could be done.


  • There are many claims issues on TriZetto that have simple fixes that appear to be left uncorrected:
  • Diagnosis codes need to be corrected
  • ID name and number not correct- (We are unsure where the insurance card is on some of these)
  • Claims need date of accident or date of onset of illness
  • Diagnosis codes on claims are in RED and should not ever be on claims.
  • PQRS codes have fees. These 0.01 charges are not needed. By using this system it takes the claims building team longer to complete their tasks.

**RECOMMENDATION** PQRS codes should only be used on Medicare or Medicare replacement policies.


**Concern** – There is a noticeable spike in rejection % in TriZetto for September (October’s results are not available yet).  The TriZetto average error rate for all customers is around 5% and TIM’s error rate was around that average prior to September.  In September, that error rate jumped to 10%+


**RECOMMENDATION**  Assess why such an increase in error rate – – are there new staff members who are building claims?  Other issues that the practice may be aware of? Credentialing?  New front desk person perhaps entering incorrect patient demographic information?


  • How far back are claims built?
  • After a look at the work list, it appears that there are claims signed but not built back to 09/20/13


**RECOMMENDATION** Have a staff member run an unsigned notes report at the end of each month and then run the worklist back 6 months each month to catch any notes that may have been signed off during that time.

  • Modifier Issues:
  • In our snapshot random sampling, we discovered several 59 modifiers on 90471 CPT codes and 25 modifiers on preventive visit codes, when no modifier is on the office visit. This would lead to denials.



  • Claim Building Practices:
  • There are multiple claims for same patient with same date of service. (One patient had 7 claims for 10/02/13) It could be an issue with too may CPT codes per invoice or perhaps too many ICD9s. We imagine that a process like this could result in increased error rate (modifier needed across multiple invoices, etc.); however, without a better understanding of the need for the process, we can only comment on what we see.


  • There are many claims that have not transmitted but are set to EF. If a claim is set to “EF” in the system that means it is set to file to insurance. 


**RECOMMENDATION** Check the insurance setup.  If it is not correct those claims could sit in e-MDs and not be transmitted.  Revenue would certainly be lost.


  • From a claims perspective, it appears that there is a specific process involved in building claims – there are multiple invoices for the same DOS.


  • It appears that the staff is spending a great deal of time obtaining ABN waivers for almost all services (there are a great deal of flu vaccines involved as well).

**QUESTION**  Has there been an issue in the past where ABNs were needed, but were not obtained?  And did that result in ABNs being required for almost all services?   The time spent collecting these, scanning them into Docman, and then adding the GA modifiers may not be necessary in all cases and is something to consider moving forward.


  • Coding issues:
  • Modifiers 59, 25 are not always being used correctly (see Claim Editing Examples above)



Payment Posting:


  • TriZetto EDI Clearinghouse Issues
      • Good enrollment with payers for ERA/EFT
      • CA BCBS (ERA, checks/EFT)
      • CA MDD (ERA, EFT)
      • CA MDC (ERA, EFT)
      • RR MDC (ERA, EFT)


                        **RECOMMENDATION** There are other insurance carriers who offer ERA   (electronic remittance advice/electronic EOBs) that could be signed up for through TriZetto –

                        Ex:  Aetna, Tricare for Life, AARP supplement, ChampVA, UHC, Cigna, etc.

                        Some of these payers may also offer EFT, which would be a separate enrollment.


                        **Result:  Opportunity for more electronic posting, better access to information in TriZetto for EOB reference.  This would increase efficiency for your posting team members.


  • ERA files are being downloaded consistently from TriZetto for posting – payments are being posted from TriZetto within 3 business days of their arrival in TriZetto and often sooner.


  • There is a good degree of consistency with staff involved in insurance payment posting for the practice
  • Team members S. Davis, B. Tadlock, K. Charles are involved. Tadlock is involved primarily with electronic posting of MDC and BCBS.   


  • Electronic posting:
  • Whomever set up the electronic posting in this practice had a good understanding of e-MDs or good training (or both) – there are reason codes that had to be changed in order for electronic posting to work correctly and (for the most part) – the reason codes that need to be adjusted off automatically are set in that way.

**RECOMMENDATION** (The practice may want to check on the B9 for hospice and some of the denials for duplicate)


  • It appears that the “Accept Batch” button is being used:
  • The situation of changing from “I” to “P” in terms of claim responsibility is both for electronic posting and posting by hand. Once a claim is finalized, balance should be shifted to Pt (even if $0 balance). –
  • Ex – inv. 42069  42080  45275  17678

**RECOMMENDATION**  We normally do not recommend using this button because it does not allow a payment poster the opportunity to confirm/file secondary claims (if needed) and balances for insurance are being left out to insurance that need to be flipped to patient responsibility.  



Posting analysis of EFTs dated 10/8/13 – 10/12/13  from TriZetto:


Overall, with such a high volume of payments, the posting entries are good.  When there are denials for coding or insurance, it is difficult for Solor to tell what process may be in place (if any) for how to address the denials.  Some denials were not being re-filed correctly and there is a lack of documentation about the edits being made.  The chart below represents specific invoices from this set of EFT payments where the entries need further analysis:



Invoice Issue
41947 MDC – non-covered/PR50.  the filing to secondary has not been set
41881 MDC – CO50 on the 80061.  no GA to indicate ABN signed.  Should be adjusted off – cannot bill the Patient(pt).
41927 Did not forward to secondary per MDC and no secondary ins. in demographics – needs to be flipped to pt.
42479 MDC – the B15 denied code should not be adjusted off – this is a coding issue
42493 The coding for 90472 is not correct – the Gxxxx admin. Code does not count as the first vaccine admin in order to use 90472.   A G0471 is correct with the appropriate modifier on the Gxxxx code
45271 Denied on the G0402-25 for a coding issue.  No invoice notes made and this claim has not been re-filed.  What action was taken? 
35064 Rendering provider was blank on the 99495.  No inv. Notes made and claim has not been re-filed.
43456 Pt. is under hospice care.  All invoices for this pt. denied.   The issue has not been addressed correctly – the payment posters or claims builders may not have a good understanding of how hospice claims should be processed.  Filing as tertiary to hospice is not correct.



**Concern – denials are not being addressed/addressed correctly (same date range):


Inv. 40433 Denied 10/11 MDC – refilled as new inv. 47882.  Why??
Inv. 44231 Denied 10/11 MDC – incorrect name/ID.  Re-filed 10/14 with no invoice notes, but still not correct based on the denial. 
Inv. 36574 Denied 10/11 MDC – modifier issue.  Re-filed 10/14 without the 25 modifier – documentation?
Inv. 44513 Denied 10/11 MDC – invalid pt. address.  Re-filed 10/14 with no invoice notes, but pt. address is still a problem.  9 digit zip code is needed and this pt. only has 5 digits. 
Inv. 44487 Same as immediately above for 44513
Inv. 32177 Denied 10/11 MDC  – incorrect name/ID.  Re-filed 10/14 with no inv. Notes, but still not correct based on the denial
Inv. 43968 Denied 10/10 MDC – pt. enrolled in hospice.  Filed as tertiary claim to hospice carrier – not correct.
Inv. 44915 Denied 10/10 MDC for other procedure same DOS – coding issue on the 99214  denial posted 10/10, no inv. Notes.  What is the follow-up process here for claims edits?
Inv. 39888 Exact same issue as immediately above for 44915
Inv. 32208 Denied 10/10 MDC – incorrect name/ID.  Re-filed 10/10, but still not correct
Inv. 36860 Denied 10/10 MDC – pt. enrolled in hospice.  Filed as tertiary claim to hospice carrier – not correct.



  • Check dates – posting by hand / flip to pt / Adj types:
  • The entry for check date should be the actual check date or EOB date, but the poster is not using the field correctly.
  • Ex – inv. 42054
  • Balance needs to be flipped to pt.
  • Is the office not contracted with UHC? A contractual adj. was not taken.
  • The PR3 (copay due) is not correct.
  • This was entered as a BCBS adjustment type (was that intentional?)
  • The actual check date is 9/30, but was entered as 10/4.
  • The leading letters of UHC checks are part of the check #, but are not being entered.
  • GREAT to see that the paper payments are being scanned into the postings – this way there is a permanent record for any questions.
  • Ex – inv. 38847
  • Check # for Tricare for life should include the leading letters.
  • The balance needs to be flipped to pt.
  • The check date was 9/26, but was entered in the posting as 10/14.
  • Entry with MDC adj. type for Tricare for Life is not correct.



Follow Up:


  • Collections Modules are not run on a regular basis.
    • Last modules ran 03/27/13
    • Ran current modules:
      • Ins Resp > 30 days = 1813 claims/$139288.73
      • Ins Cred > 60 days = 261 claims/$7137.70
      • PT Resp > 60 days = 3590 claims/$211853.72
      • PT Cred > 60 days = 629 claims/$12481.10
    • Large buckets on insurances:
      • BCBS – 25.76% of AR
      • Medicare Part B – 61.45% of AR


  • Insurances Created:
    • “FAKE” insurance created in system showing $6 balance
    • “ZZZZZBLUE” insurance created in system showing $78 balance.

**RECOMMENDATION** False insurances should not be created in the system.


  • Over sending statements to patients and not sending out letters:
    • Inv#18711, 18952, 15335

**RECOMMENDATION** Use a three step letter campaign in addition to statements prior to sending a patient to collections.  If nothing else, establish a uniform procedure for all patient responsibility accounts.


  • There are no account notes on most claims. We are not sure what the collections procedure is because of this fact.
  • Inv# 15705, 4073, 6512-6514

**CONCERN**  This is an area where most practices are not fully utilizing the e-MDs system.  Without documenting in the invoice notes section of an account, how does a follow up team member know what’s been done regarding an account?  Additionally, how does a practice manager or provider know?

**RECOMMENDATION** Use the invoice notes section of a claim to document all interactions with insurance representatives and actions taken on Navinet and other insurance websites when adjudicating a claim.


  • Showing copays on patient insurances even when they have secondary insurance. This causes the front desk to collect payment and in turn creating credit balances.
    • Inv# 2558, 2430, 3707

**RECOMMENDATION** When a patient has a secondary insurance, do not include a copay in the demographics insurance set.  This will eliminate many patient credits which are time consuming and cost the practice money in staff time, check costs, and postage.


  • Not using the proper pre-pay procedures for collecting copayments: Prepayments are being put under “ONLY PAYMENT” on their own invoice.  Again, this creates credit balances.  This money can also be transferred to other claims that have balances.
    • 67 claims found
    • Inv# 4704, 23293, 59, 44508
  • The practice is scheduling patients for a wellness visit and a separate appointment for labs on same day. This is resulting in claims being split.  The split claims are causing denials.
  • Inv# 43781, 43810, 43811
  • No recommendation for this other than to ask what workflow issue is in place to have this policy created.


  • Practice is being underpaid because of the fee schedule being incorrect.
  • CPT 99381-99397, 99213, 99214, 36415, 99000
  • Inv# 4959, 3586, 2430, 4693

**RECOMMENDATION** Set your fee schedule to a minimum of 160% of Medicare’s allowable amount




General Findings:


  1. **Good start for ERA and EFT in TriZetto.  Continue to look for opportunities to add additional ERA/EFT for specific payers.


  1. **Payments in TriZetto are being posted in a timely manner.  Electronic posting is good – what process for looking for secondary’s to be filed when posting electronically?


  1. **TriZetto rejections are not being worked (and/or are not being marked as completed).  Over $235,000 in claims on the TriZetto rejections dashboard.   Whose responsibility on your staff is it to work those denials?  Most are easy to fix and would help on the collections side to get things resolved.
  2. Is the staff aware that these rejections are there and have to be worked?  If they are being worked (the ones that we checked at random had no inv. Notes and had not been refilled), does the staff know that there is an option in TriZetto to notate when a denied claim has been “worked”? (Ex – inv. 44162  34348  38570) 


  1. **TriZetto error rate for the practice has doubled from 5% to 10% from August to September.   Change in office staff, new claims builder, other??


  1. **Posting – Once posted, invoice (even those with $0 balance) need to be flipped to pt. resp. once all insurance has responded.  Claims are often being left out to insurance that have adjudicated completely


  1. **Posting by hand – keep an eye on the Adj. type being selected, the entire check number (including any leading letters), and the check date.


  1. **Patient payments being posted by hand – why not using the prepayment function?  Posting the payments in prepay and then distributing them from that function would allow for a better assessment of when the last pt. payment was made, which in turn, would give an idea of when overdue notices should be sent or when patients could be sent to collections.


  1. **How often are statements being sent?   Are they being printed from e-MDs as needed or batched to TriZetto monthly?


  1. **Is someone printing paper claims for the office?  Are they checking the HCFA wizard consistently?


  1. **Claims for patients under hospice care are not being addressed correctly.  Once a patient under hospice care is identified, claims should be treated in the same way from the hospice enrollment date moving forward.  Perhaps the claims editing team and posting teams are not aware of the correct process?


  1. **Follow-up: What is the office process for follow-up on old DOS?  Is there a cut off based on invoice date?


  1. Are they using the collections module?

            (Ex – Inv. 9758  29263  29265  34685 – same patient, COB issue, filed multiple times, no invoice notes to indicate what may be going on.)





Claims Building: B-

Basic procedures are generally being followed.  However, there are inefficient processes that are negatively impacting the practice’s bottom line (Fixing simple claim rejections on the dashboard, etc.).  Additionally, the rate of rejections has doubled in recent months.


Posting: B-

Process for posting of payments appears to be standard, especially for the high volume of workload.  There are some e-MDs specific workflows that are being misused and demographics entry seems to be a major issue causing denials as well.


Denial Follow Up: D-

There is no consistent use of the collections module, nor is there any evidence of invoice note documentation to substantiate that any consistent follow up is taking place.  With over $235,000 in rejected claims on the TriZetto dashboard, there seems to be a lack of clarity as to who on the staff should be accountable for keeping those dashboards clean.  In our opinion, this would be a place where additional processes should be created and/or current processes be re-assessed to increase efficiency and accountability in this critical area of the billing cycle.


So as you can see, Solor is quite thorough in our details and examples even though this is a basic billing audit.  So how much does something like this cost?  Most basic billing audits are between $1800.00- $2500.00 depending on the size of the practice and the scope of the project.  Our customary charge is $150.00 per hour for the project and most projects take between 12-16 hours to complete.  Solor provides a written audit report to the practice and Solor’s leadership staff is available by video conference call or phone to discuss the results and answer any questions that the practice might have.


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Solor is a specialized third party medical billing company for e-MDs® Practices.  e-MDs® is a registered trademark of e-MDs Inc.  e-MDs Inc. is not affiliated with Solor, Inc., our products, services, or website.  Additional legal disclaimer here:  http://wp.me/P7cvJE-kI

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