RCM audit · diagnostic review

Know what is working before you decide what to fix.

An independent review of revenue cycle performance, billing accuracy, coding quality and revenue leakage.

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Audit scope mapWhere the sample review left each stageSample audit scope · Illustrative

Reviewed · no issue
Finding
Needs deeper review

EligibilityFinding

Coverage checks happened, but not always before the visit.

Illustrative scope for a fictional practice. Not a Kitronixe result or a client’s audit, and there is no overall score: each stage is described by what the evidence showed.

Which question are you asking?

Revenue IntelligenceWhere did the money go, and why?Trace revenue movement, leakage and its financial root causes.
Practice AnalyticsHow is the practice operating?See provider, patient-access, location and operational performance.
RCM AuditYou are hereIs the revenue cycle working the way it should?Test workflows, document findings and prioritize remediation.

Why an audit is different

An audit is an investigation, not a standing report.

Reporting and intelligence watch the revenue cycle continuously. An audit stops, looks closely at a defined scope, and tests whether the work matches how it is supposed to run.

RCM Audit compared with Practice Analytics and Revenue Intelligence
Dimension	RCM AuditThis page	Practice Analytics	Revenue Intelligence
The question	Is the revenue cycle working the way it should?	How is the practice operating?	Where did the money go, and why?
What it is	A diagnostic engagement: a defined scope, sampled work, tested controls and documented findings.	Ongoing management visibility across providers, scheduling, locations and throughput.	Financial intelligence across claims, remittances, payments, denials and A/R, ongoing or for a targeted question.
Time frame	Point in time, for an agreed period and scope	Ongoing, on a regular reporting rhythm	Ongoing, or targeted at a specific question
What the practice receives	Evidence-backed findings, priorities and a remediation roadmap	Operational views the management team uses to decide and monitor	Patterns, root causes and where revenue is moving

RCM AuditThis page
The question
Is the revenue cycle working the way it should?
What it is
A diagnostic engagement: a defined scope, sampled work, tested controls and documented findings.
Time frame
Point in time, for an agreed period and scope
What the practice receives
Evidence-backed findings, priorities and a remediation roadmap
Practice Analytics
The question
How is the practice operating?
What it is
Ongoing management visibility across providers, scheduling, locations and throughput.
Time frame
Ongoing, on a regular reporting rhythm
What the practice receives
Operational views the management team uses to decide and monitor
Revenue Intelligence
The question
Where did the money go, and why?
What it is
Financial intelligence across claims, remittances, payments, denials and A/R, ongoing or for a targeted question.
Time frame
Ongoing, or targeted at a specific question
What the practice receives
Patterns, root causes and where revenue is moving

An audit is a point-in-time diagnostic with an agreed scope. It can show whether ongoing reporting or intelligence would help, but it does not replace either of them, and neither of them replaces an audit.

How the review runs

Seven steps from scope to remediation.

Every finding can be traced back to the sample and the evidence that produced it.

An audit is useful when it tells you something you did not already suspect. Kitronixe audits look at what is actually happening in the data rather than at what the process document says should happen.

Step 1: ScopeAgree the stages, period, locations and questions the review will cover.
Step 2: SampleSelect encounters, claims and balances that represent the work in scope.
Step 3: TraceFollow each sample from registration to its current state.
Step 4: VerifyCheck the evidence at each stage against the practice’s own intended workflow.
Step 5: DocumentRecord each finding with the evidence behind it and the area it sits in.
Step 6: PrioritizeRank findings by operational impact and how readily they can be addressed.
Step 7: RemediateAgree actions and owners, and what to re-check once changes are made.

What gets audited

Each domain has its own evidence and its own test.

Select a domain to see what is in scope, what evidence is reviewed, how it is tested and what a finding there can look like. The scope is agreed for each practice; nothing here is a universal requirement.

Eligibility

Scope: How and when coverage is confirmed before services.
Evidence reviewed: Coverage checks and their timestamps, where the system records them.
Test performed: Sample verification timing and completeness against the practice’s intended point of check.
Potential finding: A process gap in timing, no issue, or a need for deeper review of a specific plan type.

A domain can end the review as:No issueProcess gapDeeper review

Sample, then trace

One encounter, followed from registration to A/R.

The heart of an audit is tracing sampled work through every stage it touched. Choose a sample to see, stage by stage, whether evidence was available, whether the intended workflow was followed and whether an issue was observed.

Encounter evidence trace

Choose a sample; each stage is checked against the evidence

Sample encounters · Illustrative

Office visit · Payer A · established patient (fictional) · 1 stage with an issue observed

Sample 1 traced stage by stage: evidence, workflow and issues observed
Stage	Evidence available?	Workflow followed?	Issue observed?	What the reviewer noted
Registration	Yes	Yes	No	Intake details on file and matched the claim.
Eligibility	Yes	No	Yes	Coverage was checked after the visit, not before it.
Authorization	N/A	N/A	N/A	No authorization requirement identified for this service and payer.
Documentation	Yes	Yes	No	Note completed before the claim was prepared.
Coding	Yes	Yes	No	Coded services supported by the note in this sample.
Claim	Yes	Yes	No	Pre-submission review recorded.
Remittance	Yes	Yes	No	Remittance received and matched to the claim.
Payment	Yes	Yes	No	Payment posted and tied to the deposit.
A/R	N/A	N/A	N/A	No insurance balance remained.

Registration
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Intake details on file and matched the claim.
Eligibility
Evidence available?
Yes
Workflow followed?
No
Issue observed?
Yes
Coverage was checked after the visit, not before it.
Authorization
Evidence available?
N/A
Workflow followed?
N/A
Issue observed?
N/A
No authorization requirement identified for this service and payer.
Documentation
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Note completed before the claim was prepared.
Coding
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Coded services supported by the note in this sample.
Claim
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Pre-submission review recorded.
Remittance
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Remittance received and matched to the claim.
Payment
Evidence available?
Yes
Workflow followed?
Yes
Issue observed?
No
Payment posted and tied to the deposit.
A/R
Evidence available?
N/A
Workflow followed?
N/A
Issue observed?
N/A
No insurance balance remained.

What each stage checks

Registration: Demographics and insurance details captured at intake.
Eligibility: Coverage confirmed for the date of service.
Authorization: Any requirement identified and tracked, where applicable.
Documentation: Note complete before the claim was prepared.
Coding: Coded services supported by the documentation.
Claim: Claim reviewed and submitted.
Remittance: Payer response received and read.
Payment: Payment and adjustments posted and reconciled.
A/R: Any remaining balance has a documented next step.

Illustrative samples from a fictional practice, with generic payers and no patient details. Not a Kitronixe result or a client’s audit. A single sample shows where to look; a pattern needs more than one before it becomes a finding.

Testing the controls

Does the safeguard actually hold?

A workflow can be written down and still not happen. Each control question is tested against sampled work, and each result is recorded as a pass, a finding, or a request for more evidence.

Control test log

Each question tested against sampled work

Sample test results

1.Is eligibility checked at the intended point?
Test: Compare check timestamps with visit dates for the sample.
Observed: Some sampled checks ran after the visit rather than before it.
Finding
2.Are authorization requirements tracked?
Test: Look for a tracked requirement before each sampled service where one applied.
Observed: A tracking log exists; entries for some sampled services could not be located.
Needs evidence
3.Are claims reviewed before submission?
Test: Confirm a review step ran on sampled claims and what it caught.
Observed: A review step was recorded on each sampled claim.
Pass
4.Are denials categorized?
Test: Check that sampled denials carry a category that points to a cause.
Observed: Sampled denials were worked but not categorized by cause.
Finding
5.Are payments reconciled?
Test: Tie sampled deposits to posted payments and adjustments.
Observed: Sampled deposits tied to posted payments.
Pass
6.Is old A/R actively worked?
Test: Check older sampled balances for a recent, documented next step.
Observed: Several older sampled balances had no recent documented next step.
Finding
7.Are management reports reconcilable?
Test: Rebuild selected report figures from source data.
Observed: Source extracts were requested to rebuild two report figures.
Needs evidence

Illustrative results for a fictional practice. Not a Kitronixe result or a client’s audit. This is not a certification checklist: a pass means the sampled work followed the practice’s own intended workflow, not that anything has been certified, attested or approved.

Documented findings

Every finding carries its evidence, owner and next action.

Findings are written so they can be acted on: what was observed, where, on what evidence, what kind of impact it has and who owns the fix.

Findings log · excerpt

Six of the findings from a fictional review

Sample findings

Sample findings with area, evidence, impact type, severity, action, owner and status
Finding	Area	Evidence	Impact type	Severity	Recommended action	Owner	Status
F-01Eligibility checked after the visit in part of the sample	Eligibility	Check timestamps against visit dates for sampled encounters	Rework and delayed payment	High	Move the check to the day before the visit and log it	Front desk lead	Action agreed
F-02Denials worked without a cause category	Denials	Denial records and notes for sampled claims	Causes not visible to management	High	Introduce a short category list and apply it to every denial	Billing team lead	Open
F-03Older balances without a documented next step	A/R	Follow-up notes and next-action dates for sampled balances	Cash delay	Medium	Require a next-action date on every balance past the practice’s follow-up threshold	A/R lead	Open
F-04Claims prepared before notes were signed	Documentation	Note sign-off times against claim preparation times	Rework and correction risk	Medium	Hold claim preparation until the note is complete	Practice manager	Action agreed
F-05Adjustments posted without a documented reason	Payments	Posting records and adjustment notes for the period	Reporting reliability	Low	Add a required reason to manual adjustments	Posting lead	Open
F-06Authorization tracking could not be confirmed for some services	Authorization	Authorization log entries for sampled services	Not yet determined	Medium	Pull the full log for the period before drawing a conclusion	Practice manager	Awaiting evidence

F-01 · EligibilityEligibility checked after the visit in part of the sampleHigh
Evidence
Check timestamps against visit dates for sampled encounters
Impact type
Rework and delayed payment
Recommended action
Move the check to the day before the visit and log it
Owner
Front desk lead
Status
Action agreed
F-02 · DenialsDenials worked without a cause categoryHigh
Evidence
Denial records and notes for sampled claims
Impact type
Causes not visible to management
Recommended action
Introduce a short category list and apply it to every denial
Owner
Billing team lead
Status
Open
F-03 · A/ROlder balances without a documented next stepMedium
Evidence
Follow-up notes and next-action dates for sampled balances
Impact type
Cash delay
Recommended action
Require a next-action date on every balance past the practice’s follow-up threshold
Owner
A/R lead
Status
Open
F-04 · DocumentationClaims prepared before notes were signedMedium
Evidence
Note sign-off times against claim preparation times
Impact type
Rework and correction risk
Recommended action
Hold claim preparation until the note is complete
Owner
Practice manager
Status
Action agreed
F-05 · PaymentsAdjustments posted without a documented reasonLow
Evidence
Posting records and adjustment notes for the period
Impact type
Reporting reliability
Recommended action
Add a required reason to manual adjustments
Owner
Posting lead
Status
Open
F-06 · AuthorizationAuthorization tracking could not be confirmed for some servicesMedium
Evidence
Authorization log entries for sampled services
Impact type
Not yet determined
Recommended action
Pull the full log for the period before drawing a conclusion
Owner
Practice manager
Status
Awaiting evidence

Illustrative findings for a fictional practice. Not a Kitronixe result or a client’s audit. No dollar impact is shown, because none is stated without evidence to support it.

Severity is illustrative prioritization for a fictional practice: how much operational attention a finding may need. It carries no regulatory or legal significance, and it is not a score, a grade or a certification outcome.

Where the findings cluster

Grouping findings by workflow area shows whether problems are scattered or concentrated. A cluster usually points to one process worth fixing rather than many separate errors.

Findings by workflow area

17 findings in a fictional review, by priority

Illustrative data

High
Medium
Low

Findings by workflow area and priority, fictional review
Area	High	Medium	Low
Front desk & eligibility	1	1	1
Authorization	0	1	1
Documentation & coding	0	2	0
Claims	0	0	1
Denials	1	1	1
Payments	0	0	2
A/R	0	2	0
Reporting	0	1	1

Illustrative counts for a fictional practice. Not a Kitronixe result, a client’s audit or a benchmark. Priority is illustrative and carries no regulatory or legal meaning.

From findings to a plan

Decide what to fix first, and what to leave for later.

Findings are placed by their operational impact and how readily they can be addressed. Select a finding to see why it sits where it does.

Remediation map

The sample findings, placed by impact and ease

Sample prioritization

Operational impact →

Ease / urgency of fixing →

F-01 · Eligibility

Eligibility checked after the visit in part of the sample

Fix firstHigh

Why here: High operational impact and readily addressed: act on these now.

Recommended action: Move the check to the day before the visit and log it

Owner: Front desk lead

Illustrative placement for a fictional practice. Not a Kitronixe result or a client’s audit. Positions are a judgement made with the practice, not a calculation, and no dollar value is attached to any finding.

The deliverable

A written report you can act on.

The review ends in a document, not a slide of scores. Choose a section of the sample contents to see what it holds.

Revenue cycle review · Sample practice

Audit report

Sample report layout

What the review covers

The areas this engagement can include. The scope is agreed with each practice.

Billing auditAccuracy, timeliness and completeness of claim submission.
Coding auditSampled against documentation.
Revenue leakage auditWhere earned revenue is being lost.
Workflow assessmentWhere the process and the practice diverge.

Contents

Section 1 · page 2

Executive summary

The scope, the period reviewed and the handful of findings that matter most, in plain language.

Illustrative report layout for a fictional practice. Not a Kitronixe client result; the contents of a real report depend on the agreed scope.

Audit questions

How an RCM audit works in practice

All FAQs

What does an RCM audit cover?

The scope is agreed before the review starts. It can cover front desk and eligibility, authorization, documentation timing, coding against documentation, claims, denials, payments, A/R and management reporting, or a subset of them. A narrower scope is often more useful than a broad one when there is a specific concern.

How are samples chosen, and what evidence is reviewed?

Samples are selected to represent the work in scope for the agreed period, for example encounters, claims and open balances across the payers and locations involved. For each sample we review the records the practice already keeps: registration and coverage checks, authorization logs, note status, claim history, remittances, posting and follow-up notes. The sample is small enough to trace thoroughly, so findings describe patterns worth confirming rather than a statistical measurement of the whole practice.

How are findings documented?

Each finding records what was observed, the workflow area, the evidence it rests on, the kind of impact it has, a priority, a recommended action and a suggested owner. Priority is a practical ranking of where to act first. It is not a regulatory or legal classification, and the review does not produce a score or grade.

What does the deliverable include?

A written report with an executive summary, the evidence-backed findings, workflow gaps, priority actions, data and reporting observations, a remediation roadmap and follow-up recommendations. We walk through it with your team so the findings are understood by the people who will act on them.

What happens after the audit?

Your team decides which actions to take. Some practices fix findings internally; others ask for help with specific areas such as denial management or A/R. We recommend a follow-up check on the highest-priority findings once changes have had time to take effect.

How is an audit different from ongoing RCM services or reporting?

An audit is a point-in-time diagnostic with a defined scope. Ongoing RCM services do the work every day, Practice Analytics gives management continuous operational visibility, and Revenue Intelligence traces where revenue is moving. An audit can tell you whether any of those is needed, but it does not replace them.

Does the audit certify our revenue cycle or give a legal opinion?

No. An RCM audit is an operational review. It does not certify, attest to or grade a practice, and it is not legal or regulatory advice. Where a finding raises a question that needs legal or compliance counsel, the report says so.

Start with evidence, not assumptions.

Tell us what prompted the question and which stages concern you most. We will propose a scope and a sample that fit, before any work begins.