What does a retrospective audit evaluate?

What does a retrospective audit evaluate?

• A. It analyzes current claims against pending standards.
• B. It reviews provider compliance with patient satisfaction metrics.
• C. It evaluates whether services previously reported to a carrier were reported appropriately, and consistent with binding carrier rules.
• D. It assesses the efficiency of the billing workflow.

Answer: (C)

A retrospective audit looks back at claims that have already been submitted to a payer to verify that reporting was correct and consistent with carrier rules. It examines past submissions to ensure services previously reported to a carrier were documented properly, using the correct codes and modifiers, and in line with binding payer guidelines. This helps catch misreporting, ensure compliance, and identify areas for correction or retraining. The other possibilities focus on different ideas: analyzing current claims against standards that are pending is about forward-looking checks rather than past submissions; reviewing provider satisfaction metrics relates to quality outcomes rather than billing accuracy; and assessing billing workflow efficiency targets the process itself rather than whether claims were reported correctly to a carrier.

A retrospective audit looks back at claims that have already been submitted to a payer to verify that reporting was correct and consistent with carrier rules. It examines past submissions to ensure services previously reported to a carrier were documented properly, using the correct codes and modifiers, and in line with binding payer guidelines. This helps catch misreporting, ensure compliance, and identify areas for correction or retraining.

The other possibilities focus on different ideas: analyzing current claims against standards that are pending is about forward-looking checks rather than past submissions; reviewing provider satisfaction metrics relates to quality outcomes rather than billing accuracy; and assessing billing workflow efficiency targets the process itself rather than whether claims were reported correctly to a carrier.