Audit

A systematic review and examination of a provider's or organization's records, processes, and compliance with credentialing standards, regulatory requirements, and contractual obligations.

In healthcare, an audit is a systematic review of your documentation, billing, coding, or compliance practices. Audits can be internal (conducted by your own practice) or external (conducted by a payer, a government agency, or an accrediting body). Payer audits are the ones that affect credentialing directly. After you are credentialed and actively billing a payer, they may audit your claims to verify that the services billed were actually provided, that the documentation supports the level of service billed, and that the coding is accurate. If an audit finds systematic overbilling, the payer can demand repayment, terminate your contract, and report you to the OIG. Medicare conducts audits through several programs: the Recovery Audit Contractor (RAC) program, Targeted Probe and Educate (TPE) reviews, and Zone Program Integrity Contractor (ZPIC) investigations. Being selected for a Medicare audit does not mean you did anything wrong. RAC audits are often random, and TPE reviews target providers who bill above statistical norms. Internal audits are your best defense against external audit problems. Review a random sample of your charts and claims monthly. Check that your documentation supports the codes billed. Look for common errors like upcoding, unbundling, and missing modifiers. Fix problems proactively before a payer finds them. From a credentialing standpoint, some payer applications ask whether you have ever been subject to a payer or government audit, and if so, what the outcome was. A history of audit findings is not automatically disqualifying, but a pattern of billing problems will raise concerns during credentialing review.