Coding Compliance Audit Services

35+

Years of Expertise

1989

Serving Healthcare Since

U.S.

Based, Credentialed Staff

Specialty Service Lines

Overview

Identify Risk Before It Finds You

HMI’s specialists help healthcare organizations meet and maintain compliance with Medicare rules and regulations through comprehensive review, practical guidance, and process-improvement support. From Recovery Audit Contractor (RAC) activity to Corporate Integrity Agreement obligations, we help you understand where exposure exists and how to address it.

Whether you need to respond to a RAC demand letter, satisfy IRO requirements under a CIA, audit your compliance program, or strengthen clinical documentation, our credentialed consultants bring the regulatory depth and real-world experience to guide your team — and the education to keep improvements in place.

HMI’s coding compliance audit services cover inpatient, outpatient, and physician E/M coding, reviewed against the medical record and the final billed claim. When Medicare or a payer opens a review of its own, our RAC audit support services and billing audit and compliance review work stand behind your team through every appeal level. And when the goal is to get ahead of a review before it happens, our healthcare compliance auditing services and clinical documentation improvement (CDI) work close the gaps a RAC or CIA review would otherwise find.

What’s Included

Comprehensive Compliance Support

RAC Pre-Audit & Appeals

A comprehensive review of RAC findings cited in the demand letter against the medical record and final billed claim — testing DRG validation, medical necessity, and coding accuracy the way a RAC reviewer would. Where the record supports your original billing, we build and support the appeal through redetermination, reconsideration, and the appeal levels beyond, working against the same deadlines that govern the RAC process.

Independent Review Organization (IRO)

The IRO/claims review work required under a Corporate Integrity Agreement (CIA), including reports for the OIG, corrective-action recommendations, and staff training on current coding and billing methodologies.

Compliance Program Audit

An on-site audit of your current compliance program — questionnaires, program-manual and recordkeeping review, a sample review of records and bills, and key-staff interviews — concluding with an exit conference and recommendations.

Clinical Documentation Improvement (CDI)

An assessment of your documentation processes and medical-record review for completeness across physician and clinical staff, with education provided to all staff.

Coding Compliance Review

Inpatient, outpatient, and physician E/M coding reviewed for compliance — the same coding compliance audit work that stands behind a RAC or CIA review — with follow-up reviews and education to sustain accuracy.

Education & Training

On-site and off-site education for facilities and providers (provider-based, teaching, or independent practice) on healthcare compliance, coding, and billing — closing the loop with feedback that reduces repeat findings.

Who We Serve

Compliance and Audit Support Built for Every Facility Type

The documentation, reimbursement rules, and RAC targets differ by setting. Here is what compliance and audit exposure looks like across the facility types HMI supports.

Why It Matters

Why Compliance-Minded Organizations Choose HMI

Reduce Audit Exposure

Find and fix documentation, coding, and billing risk before it becomes an audit finding or repayment demand.

Respond to RAC with Confidence

Experienced support reviewing findings and building well-supported appeals to protect appropriate revenue.

Meet CIA / OIG Obligations

Dependable IRO claims review and reporting that satisfies Corporate Integrity Agreement requirements.

Build a Stronger Program

Program audits and education leave your compliance function measurably stronger than we found it.

Credentials & How We Work

U.S.-Based Auditors, AHIMA- and AAPC-Credentialed

HMI’s compliance consultants are 100% U.S.-based and hold AHIMA and/or AAPC credentials — RHIT, CCS, CPC, and CHC — with deep, current knowledge of Medicare rules and regulations. No compliance review or RAC appeal work is sent or subcontracted offshore, and the work stays under your business associate agreement with HMI, with no offshore subcontractors handling protected health information.

Every compliance engagement follows the same four steps described below — assess, analyze, recommend, and educate — whether the work is a single RAC appeal, a full compliance program audit, or an ongoing CDI review. You receive a written findings report identifying what the record and billed claim show, along with corrective-action recommendations and, for CIA engagements, the reporting format required for the OIG. Where the findings point to a documentation or coding pattern rather than a one-time error, we close the loop with targeted staff and provider education so the same finding doesn’t recur on the next audit.

Compliance doesn’t happen in isolation. When a review surfaces coding inconsistencies beyond the audit’s scope, our outsourced medical coding services pick up where the audit leaves off; when a finding traces back to the chargemaster, our chargemaster services address it directly. If the underlying gap is HIM leadership capacity rather than a single finding, our HIM Director Services provide interim or fractional coverage, and where findings point to broader revenue-cycle process gaps, our revenue cycle management team picks up the operational side.

“

HMI has been a great partner with MedStar Washington Hospital Center for many years. We can always count on them to support us on projects small to very large — delivering consistent, honest results and thoughtful, targeted education for our physicians.

Purvi JaniAVP, Reporting & Revenue Cycle · MedStar Washington Hospital Center

How We Work

How We Approach Compliance

Assess

We review the records, claims, program documentation, or RAC findings relevant to your situation.

Analyze

We determine whether documentation and billing are appropriate and where compliance exposure exists.

Recommend

You receive findings, corrective-action recommendations, and, where applicable, appeal support.

Educate

Targeted staff and provider education helps keep your organization compliant going forward.

Frequently Asked Questions

Compliance Services, Answered

What does it mean if our hospital receives a RAC demand letter?

A RAC demand letter means the Recovery Audit Contractor’s review is complete and your Medicare Administrative Contractor (MAC) has issued an initial determination identifying an overpayment — this is what starts the formal appeal clock. We comprehensively review the findings cited in the letter against the patient medical record and the final billed claim to determine whether the documentation and billing were appropriate, and we can assist with the appeal where the record supports it.

What are the RAC appeal levels, and how much time do we have to respond?

The Medicare appeals process moves through several levels — starting with redetermination, then reconsideration before a Qualified Independent Contractor, and on to an administrative law judge hearing for claims that meet the applicable amount-in-controversy threshold. Each level carries its own strict filing deadline, and filing within the earliest windows also affects whether the MAC can begin recouping the disputed amount while your appeal is pending. We track every deadline against the letter date so nothing is missed.

What does a compliance program audit include?

An on-site review of your current program — questionnaires to your compliance office and administrator, a review of the program manual and recordkeeping, a sample review of records and bills, and interviews with key staff — followed by an exit conference and recommendations.

What is the difference between a coding compliance audit and clinical documentation improvement (CDI)?

A coding compliance audit tests whether the codes already on a claim are supported by the documentation and CMS guidelines in effect on the date of service. A CDI review looks upstream of that — at whether the documentation itself is complete enough, across physician and clinical staff, for accurate coding to be possible in the first place. Many engagements use both together: CDI closes the documentation gap, and the coding audit confirms the result.

Do you perform IRO reviews under a Corporate Integrity Agreement?

Yes. Our specialists perform the claims reviews required under your CIA, prepare the reports required for the OIG, recommend corrective actions, and provide staff training on current coding and billing methodologies.

How often should we run a coding compliance audit?

CMS does not set a single required cadence outside of a CIA, where the audit schedule is specified in the agreement itself. Outside a CIA, the right frequency depends on your claim volume, the service lines carrying the most risk, and whether you are actively responding to RAC activity. A regular program audit paired with more frequent, focused reviews of your highest-risk service lines is a common approach — we can help you scope a schedule during an initial conversation.

What’s included in the audit findings report?

A written summary of what the record and billed claim show against the standard we tested — coding accuracy, documentation completeness, or program-level compliance depending on the engagement — along with corrective-action recommendations and, for CIA engagements, the reporting format required for OIG submission. Where the findings point to a recurring pattern rather than a one-time error, we include specific education recommendations to address it.

Are your compliance auditors credentialed?

Yes. Our U.S.-based specialists hold industry credentials such as RHIT, CCS, CPC, and CHC, and bring deep, current knowledge of Medicare rules and regulations. No review or appeal work is sent or subcontracted offshore.

What drives the cost of a compliance audit engagement?

Cost depends on the type of review (a single RAC appeal, an ongoing CDI program, or a full compliance program audit), your claim volume, and whether the engagement is a defined-term project or ongoing coverage. We scope pricing to your specific situation during the initial conversation rather than quoting a flat rate — schedule a consultation for a quote tailored to your organization.

More on RAC Audits and Compliance

Related Services

Explore More of What We Do

Stay Ahead of Compliance Risk

Protect Your Organization
with a Proactive Partner

Talk with HMI about RAC support, IRO review, a compliance program audit, or documentation improvement.

Schedule a Consultation (844) 446-9176

Coding and Billing Compliance Services That Hold Up Under Audit