Medical records auditors are often sought out by large facilities, such as hospitals or surgical facilities. The reviewer's main goal is to make sure the insurance company is billed correctly for care povided, using the correct CPT and ICD-9 codes, and that the maximum reimbursement is received. A registered nurse working on an audit capacity receives training in medical coding and insurance company policies, along with certification in medical records auditing. She performs the review and submits her findings to the facility director.
The RN who reviews medical records generally starts by picking a set of random charts from the facility. Ideally, the RN should pick patients who were seeking treatment for different problems and preferably patients with different insurance companies. The RN reviews the charts, making a list of each procedure performed on the patient and the diagnosis code matching the procedure. She then compares the list to the billing information submitted to the insurance company.
A certificate in medical auditing if often a requirement for a registered nurse to work in medical records review or auditing. To be eligible for certification, the RN must have a current nursing license, a college course in accounting or finance, and two years' experience in the field reviewing records, which may be met by working as an assistant. She also must b a member of the accrediting agency, such as the American Association of Medical Audit Specialists or the American Academy of Professional Coders. After meeting the basic requirements, a RN becomes certified by registering for the exam and receiving a passing score. Meeting the requirements and becoming certified generally takes about two years.
Billing and Coding Training
In addition to her documentation skills learned in nursing school, an RN in the medical audit, or review, field requires additional training. For instance, since the review is often performed to determine if insurance billing is handled properly, training in medical coding, including the understanding of ICD-9 and CPT coding, is often required by the facility to perform the job. Coding and billing training is generally available at local community colleges or online through various sites.
Know Your Insurance Companies
The RN conducting medical records reviews must have an understanding of various commercial insurance companies and their billing policies. Generally, this knowledge comes from working as an assistant auditor or as a medical billing specialists. She must understand the procedure for filing the initial claim and a corrected claim, the covered procedures based on the patient’s diagnosis, and the reimbursement policy for each company based on the fee schedule. Additionally, training--available via web-based training on the Centers for Medicare & Medicaid Services website--that provides acceptable billing policies and procedures for Medicare and Medicaid is also required.