According to recent data, as many as 22% of Americans who visit emergency departments receive surprise medical bills, even if the facility is part of their insurance network.⁽¹⁾ In many cases, such surprise bills result from out-of-network physicians billing for services performed at an in-network facility. Healthcare organizations often fall victim to medical billing audits as a result of compliance issues. To turn the tide and help healthcare organizations avoid costly audits, risk-based auditing software solutions such as Fi-Med Management’s REVEAL/md are being implemented in hospitals nationwide.

Out-of-network physicians billing for outstanding balances is known as balance billing. This process allows physicians to bill for outstanding balances not covered by insurance. Some facilities outsource this function, relying on individuals with no clinical experience to determine rates at which patients are charged.

In many cases, balance billing results in overpayments to physicians from commercial payers, including insurance companies and the Centers for Medicare & Medicaid Services (CMS). Regardless, outsourcing of billing practices is expected to increase by 42% through 2019.⁽¹⁾

Adrian Velasquez, president, CEO and co-founder of Fi-Med Management, says, “By taking a hands-off approach to billing, physicians and healthcare organizations are exposing themselves to the risk of audits. Risk-based auditing software can help keep this process in-house by identifying billing compliance issues early, helping doctors avoid costly billing audits.”

Risk-based auditing software solutions such as REVEAL/md are being used in more facilities to manage their own billing practices and avoid outsourcing. These technologies help hospitals remain compliant and reduce the likelihood of expensive audits.

“This kind of technology really helps hospitals save money and stay on top of billing guidelines handed down by the government and insurance companies. Identifying billing compliance issues early on helps these facilities avoid audits, which can carry heavy financial penalties,” says Velasquez.