The Two Sides of Post-Payment Audits & How You Can Make the Process Easier

The Two Sides of Post-Payment Audits & How You Can Make the Process Easier

Payer audits are a necessary step in the health information management field. These post-payment audits ensure the provider is compliant with the payers’ requirements and that payers issued the correct reimbursement amount.

The “Upside” of Post-Payment Audits

Post-payment audits provide the opportunity for coders to improve upon their skills. Not only do audits identify areas of improvement and further education, but they can also prevent the usage of incorrect or outdated codes.

Since payer audits verify that the correct payment amount was reimbursed, auditors can identify instances of undercoding, overcoding, unbundling of codes, lack of documentation, and over usage of certain codes. Fixing these issues would prevent fraudulent claims and billing activity.

The “Downside” of Post-Payment Audits

On the reverse side, some healthcare organizations view payer audits as an expensive burden. Nearly one-third of providers say they’ve had a negative experience with payer audits1. One in 10 of the healthcare organizations included in the Frost and Sullivan study also noted they spend more than $1 million in payer audit administrative costs every year1.

The study pointed out the large amount of medical requests, technical denials, and cost factors of audit compliance as the main reasons providers have a negative view of payer audits1. In addition, they feel the audit process is biased to side with the payers.

However, the payer audit process can run more seamlessly if payers communicate more openly with providers. Providers offering more comprehensive responses and evidence is also a major asset. Another method that payers can adopt, called “pre-submission notification,” notifies providers of any errors before the claim is submitted for reimbursement; this reduces the likelihood for a payer audit after payment.

How to Ease the Post-Payment Audit Process

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In our experience, the post-payment audit process can run smoothly for both providers and payers. Our recommendation is for healthcare providers to find an external audit company that focuses on two elements. One, placing emphasis on empowering the coder to provide actionable feedback; and two, providing detailed reports on the audit findings that the provider can use to build strategies around.

YES HIM Consulting strives to provide these services to our auditing clients to make the process as seamless as possible. Furthermore, our detailed analysis reports break down the audit findings into easily digestible charts and graphs. This allows you to quickly identify potential deficiencies. Then, for additional mentoring, our education and coding support staff can provide custom training and coding quality improvement plans; this will help providers meet their compliance goals.

Review our article “Selecting the Right Medical Coding Auditing Company for Your Organization” to find a vendor that can take the burden out of audits.

Contact our team today if you’d like to see what a qualified medical coding and auditing vendor, like YES HIM Consulting, can do to ease the post-payment audit process.


  1. Change Healthcare, 2021.

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