How Auditing Your RCM Company Can save you money, time, and increase compliance

Summary:  This article will show you why it is vital to audit your RCM and/or billing company due to the increased auditing that is underway and will continue in terms of CCI edits, double billing, upcoding, and AI automation that will is being used by Payer organizations.

Full RCM vs Billing Companies

You can't start auditing unless you know the difference between coders, billers, and full Revenue Cycle Management (RCM). Billing companies typically focus only on claim submission and collections, often missing the upstream compliance and coding accuracy needed for sustainable reimbursement. Full RCM includes pre-service workflows, coding validation, denial tracking, encounter reconciliation, and post-payment audit readiness. For providers under increased plan scrutiny, the difference between outsourced billing and end-to-end RCM can determine audit exposure and network retention.

Why is accurate billing faster than "fast billing"

Accuracy, Delays, and Increased Efficiency are possible

Billing speed without validation often results in rework, denials, or payment delays. The fastest path to payment is not the fastest submission—it’s the cleanest claim. Clinics that prioritize code accuracy, benefit verification, and encounter alignment upfront are rewarded with shorter A/R cycles and fewer rejected claims.

Why encounter data should be a priority

Clean Data submission is the foundation for reimbursement

Encounter data tells the story of care—and if the story is incomplete, reimbursement suffers. Poorly documented encounters can lead to underbilling, upcoding accusations, or outright denials. Prioritizing encounter integrity protects clinics from audit risk and supports stronger payer relationships.

3 Signs Your Billers are placing you at a compliance risk with your payers

Duplicate billing with automated billing software:

Billing software that copies CPTs without clinical context can generate unintentional duplicates. Example: A coder selects a templated billing set for an office visit with a procedure (e.g., E/M 99214 plus 11721 for nail debridement), but the software duplicates the procedure when the provider edits the note later in the day. The duplicate claim triggers a payer review, and multiple similar instances lead to a fraud flag.

Unbundling:

Submitting services separately when they should be grouped under one code increases audit risk and may violate payer contracts. Example: A patient receives imaging and interpretation during the same visit, but the biller submits CPT codes for both services separately, thereby bypassing the bundled payment rule. The payer identifies a pattern and launches an audit for unbundling across other similar claims.

Upcoding:

Billing for higher-level services that were not actually performed is one of the most common audit triggers. Example: A new patient visit is documented as a straightforward, level 2 encounter (99202), but the biller regularly codes these as 99204 to boost revenue. This pattern doesn’t align with diagnosis complexity or visit length and raises audit flags during payer utilization reviews.

Disproportionate revenue growth compared to patient load:

When revenue rises significantly without a corresponding increase in volume or acuity, payers take notice—and often respond with audits or prepayment reviews. Example: A clinic’s revenue grows 40% year over year, but patient visits have only increased 10%, with no new service lines. The payer notices an unusual spike in level 4 and 5 office visits and flags the clinic for an upcoding and volume justification audit.