1. Claim Submission Review
✔ Verify claims are submitted within 24-48 hours of service
✔ Confirm electronic submission rate >95%
✔ Check for missing/invalid codes (CPT®, ICD-10, modifiers)
2. Payment Posting Accuracy
✔ Reconcile ERA/EOB postings against expected payments
✔ Identify underpayments (vs. contracted rates)
✔ Flag unapplied cash (mismatched payments)
3. Denial Management
✔ Track top 5 denial reasons (e.g., CO-16, CO-29)
✔ Verify appeals filed within 5-10 days of denial
✔ Audit denial recovery rate (target >75%)
4. Patient Collections
✔ Confirm statements sent within 5 days of insurance payment
✔ Review payment plan compliance (delinquency rates)
✔ Check self-pay collection rate (benchmark: >25%)
5. AR Aging Analysis
| Bucket | Target | Action If Over |
| 0-30 days | 60-70% | Monitor |
| 31-60 days | <20% | Follow up |
| 61-90 days | <10% | Escalate |
| 90+ days | <5% | Write-off review |
6. Process Gaps
✔ Identify staff training needs (coding, payer rules)
✔ Evaluate technology limitations (missing automation)
✔ Document payer-specific issues (slow processors)
Audit Frequency: Monthly (high-volume practices) / Quarterly (smaller practices)
