Sample medical billing audit report

SAMPLE. This report describes a fictional practice. It is not a real client, and the numbers are examples of the format only.

1. Practice snapshot

Practice	Example Family Medicine (fictional)
Specialty	Family medicine, 4 providers
Review period	6 months of claim activity
Data reviewed	A/R aging, denial and payer-mix reports; claim-level detail reviewed only under a signed BAA
Systems	Existing EHR and clearinghouse, no migration

2. Key measures

Measure	Finding	Common benchmark
Days in A/R	52 days	Under 40 days
A/R over 90 days	27% of total A/R	Under 15%
First-pass denial rate	11%	Under 5 to 10%
Clean claim rate	87%	95% or higher
Average days to submit a claim	6 days	1 to 2 days

3. Top findings

1. Eligibility denials (CARC 27 and 31). 38% of denials traced to coverage that changed between visits. Fix: verify eligibility before every visit, not only at the first visit.
2. Modifier 25 missing on same-day E/M and procedures. Preventive and problem-oriented visits billed together without modifier 25 were denied or bundled. Fix: coding review before submission and a short provider documentation tip sheet.
3. Medicare Advantage claims near timely filing. 41 claims over 90 days old had no follow-up note. Fix: worklist sorted by filing deadline and dollar value.
4. Underpaid commercial claims. Payments on two common E/M codes were below the contracted rate for one payer. Fix: compare ERA payments to the fee schedule and appeal short pays.
5. Charge lag. Claims waited about six days for charge entry. Fix: daily charge entry with a target of submitting clean claims within 24 hours after final review.

4. Recommended next steps

Priority	Action	Owner
1	Work A/R over 90 days by filing deadline and value	Billing team
2	Add eligibility checks before each visit	Front desk
3	Coding review for modifier 25 and preventive plus problem visits	Coding
4	Underpayment review against payer contracts	Billing team
5	Monthly report on A/R, denials and clean claim rate	Account manager

Benchmarks are common industry targets, not guarantees. Results vary by practice, specialty, payer mix, claim volume, billing history and documentation.