Any RNs doing Hospital Billing Audits?

Oct 25, 2004 07:54 AM

by SarasotaRN2b

I was just curious if there were any nurse entrepreneurs who have gone into the billing/coding field of medicine and do auditing of medical/hospital bills.

mattsmom81 · Oct 25, 2004, 09:34 AM

Interesting thought...this would be a good job for someone who likes audit work and wants a business of their own. wonder if there is demand out there/need? In my parts, insurance companies and hospitals now employ their 'own' auditors and they are wearing multiple hats I think...are in UR and CM depts, etc.

I used to do bill audits as an independent contractor, third party through a contracting agent. The actual audit was interesting, I learned a lot. The resolution was the challenge.

Insurers withheld a portion of the bill pending audit and of course the hospitals wanted their $$$, so they both want the auditor to resolve the situation immediately and in THEIR favor...LOL!

Hospitals in my parts hired their own suditors to peruse the chart and ADD charges...often based on vague nurses notes entries without corroborating billing.If it was legit I would go along with it out of honesty, but often it was not viable legally. I got tired of arguing with hospital auditors to be honest.

I learned a lot and caught a lot of mistakes...like charging $400 for an IVPB vs the actual $40 it should be...over 2 weeks of therapy that was a chunk of change. Also stuff like recovery room charges charged to the wrong patient's bill, (never had a surgical procedure). Sometimes I also found the opposite...like the hospital charged for a recovery room fee only because the surgical room charged never made it....

I ran into a lot of other nurse auditors who worked directly for the insurance company and were under more pressure to perform than I. My third party company is not longer here or I might consider returning to auditing at this point in my life.

If one enjoys negotiating/haggling and can't do bedside nursing, it might be a good fit for an older nurse or someone who wants away from clinical nursing.

Good luck to you...hopefully you will hear from nurses more up to speed with what's going on in this area! Good thread!!

SarasotaRN2b · Oct 25, 2004, 11:42 AM

Thanks Mattsmom81

I appreciate your response and I'm hoping to get some more feedback.

Originally Posted by mattsmom81

Interesting thought...this would be a good job for someone who likes audit work and wants a business of their own. wonder if there is demand out there/need? In my parts, insurance companies and hospitals now employ their 'own' auditors and they are wearing multiple hats I think...are in UR and CM depts, etc.

I used to do bill audits as an independent contractor, third party through a contracting agent. The actual audit was interesting, I learned a lot. The resolution was the challenge.

Insurers withheld a portion of the bill pending audit and of course the hospitals wanted their $$$, so they both want the auditor to resolve the situation immediately and in THEIR favor...LOL!

Hospitals in my parts hired their own suditors to peruse the chart and ADD charges...often based on vague nurses notes entries without corroborating billing.If it was legit I would go along with it out of honesty, but often it was not viable legally. I got tired of arguing with hospital auditors to be honest.

I learned a lot and caught a lot of mistakes...like charging $400 for an IVPB vs the actual $40 it should be...over 2 weeks of therapy that was a chunk of change. Also stuff like recovery room charges charged to the wrong patient's bill, (never had a surgical procedure). Sometimes I also found the opposite...like the hospital charged for a recovery room fee only because the surgical room charged never made it....

I ran into a lot of other nurse auditors who worked directly for the insurance company and were under more pressure to perform than I. My third party company is not longer here or I might consider returning to auditing at this point in my life.

If one enjoys negotiating/haggling and can't do bedside nursing, it might be a good fit for an older nurse or someone who wants away from clinical nursing.

Good luck to you...hopefully you will hear from nurses more up to speed with what's going on in this area! Good thread!!

Foxfour · Dec 10, 2004, 04:39 PM

I have both a degree in nursing and health info. mgment

Originally Posted by mccnrs2b

I appreciate your response and I'm hoping to get some more feedback.

As I mentioned in the title, I have a degree in nursing and in health information management (coding-both inpt and outpt is a big aspect of the HIM program). I know there are coders (and MD's) out there who do have this type of business. The hospital outsources their records to these companies to be coded by certified or registered coders (usually via coders who work from their homes (sweet) ). There is a shortage of coders just like there are nurses. Nurses make good coders due to the fact that your reading and putting codes to procedures. After coding, then it goes to billing. Also there are a lot of people who think that coding and billiing go hand in hand, but this is not true. In the HIM program, we didn't learn one thing about billing. As to how to go about opening a business, I'm sorry but I don't have a clue; however, I know it can be done. One other piece of info, I know the reason that a lot of billing errors occurs in pt's bills is due to the fact that a large majority of the hospitals would train people off the street to do their coding. Can you image a layperson reading, interperting and applying codes to op reports (also keep in mind that with coding comes rules and exceptions, etc.)
I hope this helps a little.

kdbtab · Aug 17, 2007, 10:48 AM