Clinical audits can take many forms. In the context of practice management, the type of clinical audit that we perform can determine where you’re making your money in your practice, where you are losing money, and where you could improve your profits.
Billing to health funds for surgical procedures can be very complex depending on the medical speciality. Even seemingly straight forward general surgical billing can have missed opportunities for revenue whereas more complex specialities such as ophthalmology and urology have special rules surrounding what can be billed and how to submit it for payment.
The Medical Benefits Schedule (MBS) changes all the time and what was fine to bill yesterday may not be today. Item codes are rapidly changing and new rules being introduced constantly and staying ahead can be difficult.
From an accountant perspective, the concentration is on revenue versus expenses, tax compliance, employee requirements and so on. It is difficult for an account to really examine a clinical practice and find where the money is. For example, if claims are rejected by health funds, or have an exception through Eclipse, these can lay dormant in practices in months before they are attended to. Debtor management tends to be the last job anyone can do because following up with health funds is time consuming and frustrating.
A clinical audit undertaken by us reviews the practice software, what was billed against the clinical notes and operation reports, to identify items that may have been missed or incorectly billed and then following this assessment through to the claim itself to what was paid. It is a specialised skill to be able to understand a fund claim payment and why or why not claims have been paid or short paid. Many practices accept adjusted claims on the face of it, particularly in high volume practices, ignoring the potential loss of revenue that could be gained by fixing a small thing in the adjusted claim.
These decisions and analysis take specialised skills and experience to find quickly and assess where the problems may exist in a practice. A clinical audit can also provide positive feedback to a practice giving the assurance that they are billing correctly and getting the most out of their billing.
A clinical audit is critical to an established practice, partnership or group practice at some point throughout its lifecycle to ensure that everyone is being treated fairly and revenue is actually coming into the practice and not being lost through lack of administration.