Revenue Cycle Audit Checklist: 20 Questions Every Practice Should Answer

Most revenue cycle problems don't announce themselves. They build quietly across months of small process failures — a missing authorization here, an unworked denial there, an eligibility check that got skipped because the schedule was busy. By the time the problem shows up in the numbers, you've already lost significant revenue.

The 100-point Revenue Integrity Audit inside the ROI platform covers all seven phases of the revenue cycle in full. This article gives you a 20-question excerpt — the highest-signal questions across those phases — so you can identify your biggest gaps in the next 30 minutes.

Answer each question honestly. If you're not sure of the answer, that uncertainty is itself the finding.

Phase 1: Patient Access and Eligibility

1. Is eligibility verified for every patient before every appointment — including established patients?
   Coverage changes frequently. Verifying at scheduling and again 24–48 hours before the appointment catches coverage lapses before they become billing problems.
2. Do your eligibility checks capture remaining benefits, not just active coverage?
   A patient can have active coverage and zero remaining physical therapy visits. If you don't check remaining benefits, you won't know until the denial.
3. Is secondary insurance identified and documented at registration?
   COB denials almost always originate at registration. If your front desk doesn't ask about secondary coverage, billing will pay for it later.
4. Is your authorization requirement list current for every payer in your system?
   Payers change their prior authorization requirements regularly. A list that was accurate six months ago may not be today.

Phase 2: Coding and Documentation

5. Is your clean claim rate above 95%?
   If fewer than 95 out of 100 claims pass first-pass adjudication, you have a coding or documentation process problem that is costing you more than just the denied claims — it costs staff time to rework every one.
6. Are your coders receiving regular feedback on denied claims?
   Denial data is your most specific coding training tool. If coders don't see which codes are generating denials, they can't fix the patterns that created them.
7. Are modifiers reviewed for accuracy before every claim is submitted?
   Modifier errors — wrong modifier, missing modifier, incorrect sequence — generate some of the most preventable denials in the revenue cycle.
8. Is there a documented policy for when to use modifier -25 and modifier -59?
   These two modifiers generate more audit risk and more denials than any others. Undocumented, ad-hoc use is a compliance and revenue risk.

Phase 3: Claims Submission

9. Do you review clearinghouse rejection reports daily?
   A claim rejected by the clearinghouse never reached the payer. If you're not reviewing rejections daily, rejected claims can sit unworked until they cross the timely filing deadline.
10. Do you track claims submission timestamps?
    In a timely filing dispute, your clearinghouse submission log is your evidence. If you can't produce it, you can't win the appeal.
11. Are all rendering and referring provider NPIs valid and current in your system?
    NPI mismatches are one of the most common CARC 16 (missing information) denial triggers. Run an NPI validation on your provider file quarterly.

Phase 4: Denial Management

12. What percentage of denied claims does your team actually work?
    Industry data suggests practices work fewer than half of their denied claims. If your answer is below 80%, you are writing off revenue that could be recovered.
13. Is there a written policy for denial appeal deadlines by payer?
    Appeal windows range from 30 to 180 days depending on the payer. Missing the deadline makes a recoverable denial permanent.
14. Do you track appeal success rates by denial reason?
    Knowing which denial types you win and which you lose tells you where to invest appeal effort and where to focus prevention instead.
15. Are root causes documented for every denial that comes through?
    Without root cause tracking, every denial is an isolated event. With root cause tracking, they become a pattern — and patterns are fixable.

Phase 5: Accounts Receivable Management

16. What are your Days in A/R and what is the trend over the past 90 days?
    A rising Days in A/R is one of the earliest indicators of a revenue cycle problem. Industry target is under 35 days for most specialties.
17. What percentage of your total A/R is over 90 days?
    A/R over 90 days is exponentially harder to collect. Industry benchmark is under 15%. Above 25% is a serious cash flow risk.
18. Do you have a written write-off policy with required approval levels?
    Without a structured write-off policy, revenue that could still be recovered gets written off prematurely — or legitimate write-offs get delayed for so long the collection window closes.

Phase 6: Credentialing and Payer Enrollment

19. Do you track credentialing expiration dates for every provider?
    A provider who bills while their credentialing is lapsed creates a denial exposure that often can't be recovered retroactively. Credentialing gaps are silent revenue killers.
20. Is there a process to verify payer enrollment before a new provider sees their first patient?
    Revenue from a provider's first 60–90 days can be delayed or lost if enrollment wasn't completed before they started billing. This is one of the most consistently underestimated revenue risks in growing practices.

How to Use Your Results

Count the questions where you answered "no" or "I'm not sure." Here's a rough interpretation:

• 0–3 gaps: Your revenue cycle is fundamentally sound. Focus on measurement and ongoing optimization.
• 4–7 gaps: You have specific process areas to tighten. Prioritize by where you're seeing the most denial volume.
• 8–12 gaps: Multiple phases of your revenue cycle have structural weaknesses. A systematic fix plan will have significant revenue impact.
• 13+ gaps: Your revenue cycle needs a comprehensive review. The ROI platform's full 100-point audit will give you a prioritized roadmap.