Compliance & Auditing

Catch billing problems before auditors do

Proactive compliance auditing, HIPAA readiness reviews, RAC audit prep, and coding accuracy analysis — so your practice is always audit-ready, not audit-reactive.

100%

HIPAA-compliant workflows

OIG sanctions — ever

Quarterly

Internal audit cycles

48hr

Audit response support

Audit Coverage

Six types of compliance risk — we cover all of them

Billing compliance isn't one thing. We audit across every risk category your practice faces.

High Risk

OIG Work Plan Audits

We review your billing patterns against the current OIG Work Plan targets — the list of services the Office of Inspector General is actively auditing this year.

Modifier 59 and X-modifier usage
Same-day E&M + procedure patterns
High-use CPT code outliers
Place-of-service accuracy

High Risk

RAC & MAC Audit Readiness

Recovery Audit Contractors (RACs) and Medicare Administrative Contractors (MACs) conduct post-payment reviews. We prepare your documentation to withstand scrutiny.

Medical necessity documentation review
LCD/NCD coverage criteria verification
Signature and authentication compliance
Overpayment risk identification

Medium Risk

Coding Accuracy Reviews

We audit a statistically significant sample of claims each quarter to measure coding accuracy and identify systematic errors before they become a pattern payers flag.

E&M level appropriateness
Diagnosis code specificity
Procedure code selection accuracy
Modifier application correctness

Medium Risk

HIPAA Compliance Review

Billing operations touch PHI at every step. We verify that your billing workflows, data transmission, and vendor relationships meet current HIPAA requirements.

BAA coverage for all billing vendors
PHI transmission security review
Minimum necessary standard compliance
Breach risk identification

Ongoing

Documentation Gap Analysis

We identify documentation patterns that create claim risk — unsigned notes, missing orders, inadequate medical necessity language — before those claims are submitted.

Provider-specific documentation audits
Template compliance review
Order and referral verification
Time-based service documentation

Ongoing

Credentialing Compliance

Billing a service under the wrong provider NPI — or while a provider is not yet credentialed — is both a denial trigger and a compliance violation.

NPI and taxonomy code verification
Credentialing status tracking per payer
Incident-to billing rule compliance
Locum tenens and covering provider rules

Our Audit Process

How a proactive compliance review works

Scope & Sample

We define the audit scope and pull a statistically valid claim sample — typically 30–50 records per provider, per quarter

Record Review

Each claim is reviewed against the documentation in the medical record — coding, medical necessity, modifiers, and signature

Risk Scoring

Findings are scored by risk level — high, medium, or low — with specific citations to CMS guidelines or payer policies

Action Plan

We deliver a written report with specific corrective actions — provider education, workflow changes, or claim amendments as needed

Common Findings

What we typically find in a first-time audit

Finding	Frequency	Risk Level	Typical Impact
E&M level unsupported by documentation	62% of practices	High	Overpayment demand, potential recoupment
Modifier 25 without distinct E&M documentation	58% of practices	High	RAC audit trigger, bundling recoupment
Missing or unsigned orders for diagnostic services	44% of practices	Medium	Denial on post-payment audit
ICD-10 codes lacking required specificity	71% of practices	Medium	Medical necessity denials
BAA not on file for a billing-related vendor	38% of practices	High	HIPAA violation exposure
Place-of-service code errors on telehealth claims	49% of practices	Medium	Claim denial, resubmission required
Incident-to billing without supervising provider present	29% of multi-provider practices	High	False Claims Act exposure

Find out what your practice's audit risk looks like

Our free revenue assessment includes a compliance risk snapshot — no charge, no commitment. Most practices have at least 2–3 high-risk findings in the first review.

Request Free Compliance Review →