Find Billing Errors Before a Payer Does
Resilient Medical Billing Services offers audit services for your medical billing that checks for claims in relation to the supporting documentation, code rules, and policies of the payers and then gives you a strategy to address them. Our credentialed auditors (CPC, CPMA, CCS, CCS-P) assess the processes that generate your revenue so that you can rectify them at your own will.
Audit Types Matched to Where Your Revenue Is at Risk
Every practice has a different exposure. Our billing compliance audit programs cover the full claim lifecycle, and you choose one service or a combined program.
Why Healthcare Audit Services Have Become a Financial Priority
Once a year was sufficient time for conducting billing review, but now it is a key protection for revenue. In FY 2025, providers under Medicare Part B had an improper payment rate of 8.44%, which is equal to almost $9.62 billion, and lack of documentation, and not fraud, is the primary cause. While the claim could have had a proper code for a particular service that was provided, it may still be denied due to lack of documentation.
Documentation Gaps Dominate
Missing records cause most improper payments.
Whistleblowers Are Surging
Record qui tam filings reached 1,297.
Analytics Flag Outliers
Federal data teams spot billing anomalies.
Overpayments Carry Deadlines
Refunds are due within 60 days.
How Our Chart Review Works, From Sample to Corrective Action?
Our medical chart audit services follow a fixed method, so findings are defensible and repeatable. Each stage produces a deliverable you can use immediately.
Scope and Risk Mapping
We start with your specialties, payer mix, and denial history, then rank the areas where errors cost the most.
Sample and Retrieval
We pull a random, representative sample of encounters per provider, with complete notes, orders, and results attached.
Two-Level Review
One auditor tests code assignment, medical necessity, and modifiers. A second auditor validates every disputed finding.
Financial Quantification
Errors are tied to dollars, separating overpayment exposure from underpaid revenue, by provider, code, and payer.
Corrective Action
You get a prioritized remediation plan, provider education sessions, and a re-audit date to confirm the fixes held.
Not Sure Where Your Claims Are Weakest?
Send a de-identified sample of recent claims and receive a no-obligation findings summary from our auditors.
Submit Your Query Now
Federal Rules and Enforcement Shaping Audit Risk in 2026
Regulators now combine tighter refund rules, prior authorization pilots, and data analytics. Billing compliance audit programs need to reflect all three.
JAN 2025 - Overpayment Standard Tightened
The review of the billing process was always an annual activity to clean up the house. Now it has become the main way to protect the income. The improper payments rate for Part B suppliers in fiscal year 2025 was 8.44%, around $9.62 billion, and the lack of documentation, rather than fraud, was the main cause of this. A claim may have the right code for the service performed, but there is no proof in the documentation.
JAN 2026 - Prior Authorization Pilot Begins
Six states have requirements whereby a health care provider has to receive authorization for certain covered services. These include Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington. Authorization lasts for 120 days; therefore, it is imperative that there is correlation between the covered services and date of authorization.
JUNE 2026 - Data-Led Enforcement Expands
This most recent operation involved 1,079 suspensions of providers and 1,403 billing privilege revocations, and 295 of the 455 defendants were charged with Medicaid fraud. The data analytics program identifies billing outliers well before any document requests come in.
FY 2025 - Medicaid and Medicare Advantage Error Rates Rise
The projected improper payment rates for Medicaid and Medicare Part C were 6.12% and 6.09%, respectively. As such, state programs and managed care organizations are reviewing claims more aggressively; hence, it is necessary to have audit-ready documentation beyond traditional Medicare.
Recovering Revenue, You Already Earned
Our medical audit recovery services cover both aspects of the problem. Improper payments made by the government involve overpayment and underpayment, and the same goes for your claims as well. Undercoding, missing charges, and underutilized add-ons have the same negative impact on your finances as denials.
We will split the findings into those that require your remediation and those that you are able to make a claim for, and then proceed to develop timely remediations and claims. In case there is a tax refund due, we will assist you in getting that process done.
| Finding Type | What We Do |
|---|---|
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Overpaid Claims
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Quantify, document, and support refund timing.
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Underpaid Claims
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Submit corrections within payer filing limits.
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Missed Charges
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Fix charge-capture gaps at the source.
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Repeat Error Patterns
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Train providers and update claim edits.
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Why Practices Choose Resilient MBS: Faster Turnarounds, Clearer Reporting
Choosing a medical billing audit company is a trust decision. These are the standards we apply to every engagement.
Independent Reviewers
Our auditors never audit claims they coded or billed.
Documented Methodology
Sampling, error definitions, and scoring rules are documented.
Dollar-Weighted Findings
We rank errors by financial impact, not by raw count.
Provider-Level Feedback
Each clinician receives specific, chart-based education.
Regulation-Aware Reviews
Rules and payer policy updates are built into every audit cycle.
Confidential Handling
Records are accessed through a system of HIPAA and encryption.
Audit Programs for Every Care Setting
Our hospital billing audit and professional fee programs adapt to your volume and risk profile.
Physician Practices
E/M level accuracy, procedure coding, modifiers, and incident-to and split/shared billing.
Hospitals and Health Systems
Inpatient DRG validation, outpatient charge capture, and medical necessity for high-cost services.
Specialty Groups
Dermatology, orthopedics, cardiology, and wound care are reviewed against the coverage policies that most often trigger audits.
Behavioral Health and Home-Based Care
Time-based codes, treatment plans, and supervision rules that regulators placed under scrutiny.
FAQs
A billing audit involves checking the claims for correct coding, medical necessity, modifiers, and payment. We identify missing documents, incorrect coding, and areas of risk of denial, followed by providing provider-specific reports, financial analysis, and solutions to ensure correctness in the future.
Internal auditing is optional and allows you to determine the timetable and any necessary corrective measures. The payer or government audit determines its own scope and timeframe, and whatever problems are identified will result in recoupment. Pre-auditing enables you to correct things at your own pace.
The number of claim tests will be determined by the number of providers, the number of claims to test, and the risk factor found. The sample size that will give meaningful results, and which can be worked on will be determined at the outset.
Take action immediately and keep a record of the process. Medicare mandates that any overpayment should be reported and repaid within 60 days. There is a limited time for the investigation regarding mistakes made. We will help gather the evidence and calculate the overpayment amount.
Yes, we conduct auditing of inpatient, outpatient, professional and Medicaid claims adhering to applicable federal and state specific billing regulations. Our audits factor in program guidelines, reimbursement policies, documentation guidelines and payment policies to detect any discrepancies.
The new vendors can be audited after a period of about three months, risky code audits quarterly and the rest annually. The frequency of audit will depend on the volume of claims and the findings made during the initial audit. We will come up with an efficient schedule.
Turn Audit Findings Into Protected Revenue
Speak with a Resilient MBS auditor and receive a risk-ranked review plan for your practice.
