Comprehensive compliance solutions tailored to your practice's needs
Identify risk, optimize revenue, and strengthen your compliance program
Chart audits are the cornerstone of a strong compliance program. The OIG recommends that healthcare organizations have an external expert conduct regular compliance audits as part of their compliance policy. Having documented audits and training shows your commitment to proper billing practices - a key mitigating factor in any OIG investigation.
We offer two types of audits to meet your needs:
If you have a specific concern - a particular payer, procedure code, or provider type that's raising red flags - we can conduct a targeted review. We'll examine the documentation and billing for your area of concern and provide detailed findings.
A comprehensive review of your practice's overall billing patterns. We analyze your claims data, select a random but representative sample, and review the corresponding documentation. This gives you a complete picture of your compliance status.
Detailed reporting designed to drive real improvement
Comprehensive performance reports for each provider showing their documentation accuracy, E/M level distribution, and coding patterns compared to industry benchmarks and payer guidelines.
Line-by-line breakdowns of specific documentation elements with auditor notes and comments, giving you a clear view of where documentation improvements are needed.
Overall group findings across all providers, identifying trends, systemic issues, and opportunities for practice-wide improvement in documentation and coding.
A high-level overview formatted for practice leadership—easy to present to stakeholders and actionable for strategic planning.
Tailored guidance for each provider on where to focus improvement efforts, with specific examples from their documentation.
Findings are designed to inform follow-up training sessions, whether group seminars or one-on-one coaching to address identified gaps.
A structured approach from kickoff to follow-up
We start by understanding your practice's size, specialty, payer mix, and specific concerns. For baseline audits, we analyze your claims data to select a representative sample. For focused audits, we identify the specific areas you want reviewed.
Our certified auditors review the selected charts against current CPT, ICD-10, and E/M guidelines, payer policies, and documentation standards. We examine medical necessity, coding accuracy, and compliance with documentation requirements.
We document all findings with specific examples, cite the relevant guidelines, and categorize issues by type and severity. This forms the foundation of all deliverables we provide to you.
You receive comprehensive reports including provider scorecards, element analysis, project summary, and executive summary. We walk you through the findings and answer your questions.
We recommend and deliver follow-up training to address identified gaps. Whether group seminars or individual coaching, we help your team improve documentation practices going forward.
Keep your team current on coding guidelines and documentation requirements
After an audit, we recommend a follow-up group training session to review findings and address common issues. We also offer standalone training on specific topics like upcoming code changes, documentation refresher courses, or new provider orientation. Sessions are available as webinars or on-site visits and include comprehensive handout materials.
Personalized training for individual providers or staff members who need additional support. Perfect for new hires, providers returning from extended leave, or anyone needing focused attention on specific coding or documentation topics.
Have a specific coding question or compliance concern? Our hourly consulting service provides expert guidance when you need it. We can research complex coding issues, review proposed billing approaches, or advise on documentation strategies.
Contact us today to discuss your practice's needs and receive a customized proposal. We work with practices of all sizes, from solo practitioners to multi-location groups.