In today’s complex healthcare environment, the mid-revenue cycle has emerged as a critical area of focus for revenue integrity leaders. It’s where clinical documentation, coding, and compliance converge—and where missteps can lead to millions in lost or delayed reimbursement. Pre-bill auditing is one of the most impactful tools for protecting revenue at this stage, ensuring that claims are accurate before they ever reach a payer.
However, as valuable as pre-bill auditing is, many organizations struggle with a central challenge: how to staff and scale the program effectively. That means not just identifying the right team structure but also equipping people with the tools and support they need to drive meaningful results.
This blog outlines how to build a high-functioning pre-bill auditing program—from leadership structure to talent development—while highlighting why technology is essential to making the model work at scale.
Why Pre-Bill Auditing Is Essential to Mid-Revenue Cycle Success
The case for pre-bill auditing is strong:
- Coding errors remain a leading cause of revenue leakage.
- Payers are becoming more aggressive with denials and documentation requests.
- Clinical documentation is increasingly complex and nuanced.
- Regulatory scrutiny around compliance is on the rise.
By auditing coded encounters before billing, health systems can mitigate these risks, reduce denials, and recapture revenue that might otherwise be lost. Pre-bill auditing also strengthens the collaboration between coding, compliance, and clinical documentation improvement (CDI) teams, creating a feedback loop that benefits the entire revenue cycle.
However, the effectiveness of this program hinges on how well it is staffed, managed, and supported.
The Core Team: What a Successful Pre-Bill Auditing Structure Looks Like
1. Leadership with Vision and Alignment
At the top, you need a revenue cycle leader—typically a Manager, Director, or VP—who understands both the operational and strategic value of pre-bill auditing. This leader is responsible for:
- Aligning audit objectives with broader revenue cycle goals
- Defining audit priorities based on financial risk and compliance exposure
- Partnering with stakeholders across coding, HIM, CDI, and billing
- Communicating clear guidelines and internal policies
- Fostering a culture of continuous improvement rather than punitive oversight
Leadership is not just about oversight—it’s about setting direction, empowering the team, and ensuring accountability across the process.
2. Auditors: The Gatekeepers of Accuracy
Auditors are responsible for reviewing coded encounters, providing feedback to coders, and identifying trends that inform future education and process improvements. But finding experienced auditors is easier said than done.
Given the national shortage of qualified HIM and coding professionals, more and more organizations are tapping into internal talent by upskilling coders into auditor roles—a highly effective, scalable approach when done thoughtfully.
Upskilling Coders into Auditors: A Smart Strategy in a Tight Labor Market
Not every coder is ready to become an auditor, but many are. The key is to identify the right characteristics and provide structured support.
What to Look for in a Potential Auditor:
- Consistently high coding quality and accuracy
- A self-motivated and inquisitive mindset
- Comfort with researching coding clinics, regulatory guidance, and payer policies
- Strong communication skills and emotional intelligence
- A desire to understand the why behind coding decisions
Onboarding Tips for a Successful Transition:
- Build Confidence Early: Emphasize that auditing isn’t about having all the answers—it’s about knowing how to find them.
- Normalize Feedback Culture: Help new auditors deliver constructive feedback as coaching rather than critique.
- Provide Clear Guidelines: Internal coding policies should be transparent and easily referenced.
- Clarify Priorities: Auditors need to know where to focus their time—high-dollar cases, high-risk DRGs, or frequent denial targets, for example.
- Use Data to Guide Education: Teach auditors how to spot trends and work with leaders to inform ongoing coder training.
Upskilling coders not only strengthens your auditing program but also boosts retention by offering a clear path for career development.
Why Technology Is Essential for Pre-Bill Auditing at Scale
Even with the best team in place, manual pre-bill auditing is not scalable. The volume of encounters in even a mid-sized hospital can quickly overwhelm a small team—especially if they’re relying on spreadsheets, static reports, or intuition to prioritize reviews.
Here’s what modern pre-bill auditing demands from a technology standpoint:
1. Automated Case Selection and Prioritization
Technology should identify which cases need auditing based on:
- Confidence in code accuracy
- Financial impact
- Regulatory risk (e.g., DRG upcoding/downcoding)
- Internal coding policy variance
This allows auditors to focus their time where it matters most.
2. Efficient, Structured Workflows
A modern solution should route encounters automatically and assign them to the appropriate auditor or coder based on rules, timelines, or specialty. Workflow automation eliminates time wasted on manual assignment and ensures nothing falls through the cracks.
3. Actionable Audit Feedback
Auditors must be able to leave feedback directly in the workflow and link it to relevant guidelines or documentation. Coders should be able to see this feedback clearly and respond if needed. This transparency builds trust and accelerates learning.
4. Trend and Pattern Analysis
Pre-bill auditing isn’t just about correcting one-off errors—it’s about identifying systemic issues. A technology platform should help surface trends over time: recurring coder errors, ambiguous documentation, provider patterns, or denial-prone diagnoses.
5. Audit Reporting and Education Planning
Leaders should be able to track audit results over time and use them to inform broader education initiatives, policy updates, or payer-specific strategies.
Bottom line: Without this level of automation and intelligence, even the most skilled auditor team will struggle to keep pace—and will likely miss the very issues that lead to denials, revenue loss, and compliance risk.
Anticipating Audit Volumes: Start with Data, Not Guesswork
One of the most common questions revenue cycle leaders ask when standing up a pre-bill auditing program is: “How many audits should we plan for?”
The answer depends on multiple factors—volume of discharges, payer mix, DRG distribution, case complexity, and financial risk exposure. But guessing won’t get you far.
A data-driven approach to estimate audit volumes is essential for right-sizing your team and setting realistic expectations. The best way to do this is by using historical claims data, such as CMS MEDPAR data, to simulate what audit volumes might look like across your case mix.
For example, many organizations use historical CMS MEDPAR data and run it through a coding analysis platform like eValuator™, which reviews 100% of encounters and flags potential coding issues based on coding or revenue integrity issues. This allows leaders to simulate likely audit volumes, pinpoint high-risk DRGs or cases, and estimate the number of auditors needed to maintain audit coverage—all before the first live audit is even run.
- Identify which DRGs or encounter types are more likely to be coded incorrectly
- Quantify the potential financial risk associated with those errors
- Establish benchmarks for how many cases may need review based on confidence thresholds
This type of retrospective modeling helps you:
- Build a baseline for expected audit volume by service line or DRG
- Determine staffing needs based on audit capacity and case turnaround expectations
- Prioritize high-impact areas where auditing delivers the most financial or compliance value
By starting with a simulation model, you don’t just guess how many auditors you need—you plan with precision and allocate resources more strategically.
Closing the Loop: People + Process + Technology
Pre-bill auditing is not a checkbox. It’s a foundational capability that helps revenue cycle teams operate with precision, agility, and insight. When staffed and supported correctly, it transforms how organizations capture revenue and ensure compliance.
Let’s recap how to get there:
- Start with strong leadership that aligns auditing with revenue goals
- Build a team of skilled auditors, and look internally to upskill coders who are ready to grow
- Create a feedback-forward culture where audit findings are collaborative and educational
- Invest in technology that automates, prioritizes, and tracks auditing with speed and intelligence
At Streamline Health, we’ve seen how impactful this combination can be. Health systems that pair empowered people with targeted technology don’t just catch errors—they prevent them. They don’t just manage risk—they drive sustainable improvement.
If you’re rethinking your approach to pre-bill auditing, start by evaluating your team structure—and then ask yourself if they have the tools they need to succeed.