The sample for prospective audits consists of what type of claims?

In the context of prospective audits, the focus is on claims that are currently in the process of being adjudicated or are being held pending the outcome of an audit. This means that these claims have not yet been finalized, allowing for the examination of documentation or supporting evidence before payment is made.

Selecting claims that are currently being held pending audit findings ensures that the audit process can influence the outcome of payment decisions, address compliance issues proactively, and mitigate potential errors before they lead to financial losses. This approach allows providers and payers to identify issues before claims are paid, ultimately enhancing the accuracy of healthcare billing and coding practices.

On the other hand, claims already paid are no longer subject to review for payment decisions, claims identified for re-evaluation may not necessarily be part of a current review process, and rejected claims due to errors are typically handled through correction and resubmission rather than a proactive audit. Thus, focusing on claims that are pending helps in improving the overall claims processing system and reduces the chances of future errors and denials.