The RCM Plus Audit Framework

At RCM Plus, medical billing audits are designed to do more than identify errors. Our audits are structured to reduce risk, protect revenue, and strengthen long-term compliance by examining every critical point in the revenue cycle.

1. Targeted Claim Selection & Risk Review

RCM Plus audits begin with purposeful claim selection, not random sampling. We prioritize claims based on:

• High-dollar and high-volume CPT codes

• Services with recurring denials

• Payer-specific risk areas

• New providers, locations, or services

This ensures the audit focuses on real financial and compliance exposure, not surface-level issues.

2. Clinical Documentation Review

RCM Plus follows a strict documentation-first approach.We review:

• Provider notes and progress documentation

• Operative and procedure reports

• Orders, referrals, and test results

Each element is evaluated against the services billed to confirm that documentation clearly and fully supports the claim.

3. Coding Accuracy Review (CPT, ICD-10, Modifiers)

Accurate coding is a core pillar of the RCM Plus audit process. We assess:

• Correct CPT code selection

• ICD-10 specificity and diagnosis alignment

• Proper modifier usage (e.g., -25, -59, laterality modifiers)

• Overcoding, undercoding, and unbundling risks

Our review addresses both compliance exposure and missed revenue opportunities.

4. Medical Necessity Validation

RCM Plus verifies that each service meets payer medical necessity requirements by reviewing:

• Diagnosis-to-procedure alignment

• Applicable payer coverage policies

• LCD and NCD criteria when required

This step directly targets medical necessity and CO-11 denial risks.

5. Charge Capture Assessment

We evaluate whether:

• All billable services were captured

• No duplicate or missed charges occurred

• Charges were entered timely and accurately

Charge capture gaps are a common source of unnoticed revenue loss, even in otherwise compliant practices.

6. Billing & Submission Compliance Review

RCM Plus audits billing workflows to ensure:

• Timely filing requirements are met

• Claims are routed correctly to payers

• Place of service and billing indicators are accurate

• Payer-specific billing rules are followed

Correct coding alone does not guarantee payment—billing execution matters.

7. Denial & Payment Trend Analysis

We analyze:

• Denial patterns by payer, provider, and CPT

• Partial payments and underpayments

• Repeated zero-pay scenarios

The objective is to identify systemic issues, not isolated mistakes.

8. Overpayment & Refund Risk Identification

RCM Plus audits proactively identify:

• Overpayments

• Duplicate payments

• Refund exposure

This allows practices to address risks before external audits or recoupments occur.

9. Compliance Gap & Risk Behavior Review

Our audits highlight:

• Repeated error patterns

• Provider-specific risk trends

• Training and process gaps

This supports meaningful corrective actions rather than punitive outcomes.

10. Actionable Audit Reporting

Every RCM Plus audit concludes with a clear, practical report that includes:

• Detailed findings

• Risk classification (low, moderate, high)

• Specific corrective recommendations

• Education-focused guidance

The goal is immediate improvement and long-term stability.

The RCM Plus Audit Philosophy

RCM Plus audits are built to:

• Prevent compliance issues before they escalate

• Protect provider revenue

• Promote accurate, defensible billing practices

By reviewing documentation, coding, billing behavior, and payer alignment together, RCM Plus delivers audits that support both compliance and financial performance.