OB-GYN Billing Mistakes That Trigger Audits — and Quietly Cost Practices $8K–$25K Per Quarter

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OB-GYN Billing Mistakes That Trigger Audits — and Quietly Cost Practices $8K–$25K Per Quarter

The Part No One Warns You About

Your OB-GYN claims are getting paid.
Your revenue looks stable.
Your billing team says things are “fine.”

That doesn’t mean your practice is safe.

Most OB-GYN audits don’t start with denials, warnings, or red flags you can see. They start silently, months after payers have already paid your claims—when the money has been spent, the charts are archived, and staff turnover has already happened.

By the time the recoupment letter arrives, the damage is already done.

The Reality Most Practices Learn Too Late

Payers don’t audit claims they deny.
They audit claims they’ve already paid.

For OB-GYN practices, audits typically occur 6 to 18 months after payment. That timing is intentional. It gives payers leverage—because now you’re being asked to return money that’s already been allocated to payroll, rent, malpractice premiums, and growth.

This isn’t a reflection of bad intent or sloppy practices.
It’s how the system is designed.

And OB-GYN billing is one of the easiest targets.

Why OB-GYN Practices Are High-Risk by Default

OB-GYN billing combines:

  • Global OB packages

  • Time-based E/M services

  • Modifiers layered onto procedures

  • Long episodes of care with multiple touchpoints

That complexity creates pattern-based risk, not one-off errors.

One audit can trigger:

  • $8,000–$25,000 in recoupments

  • Retroactive reviews of past claims

  • Automatic flags on future submissions

  • Increased payer scrutiny across all providers in the group

This isn’t a billing problem.
It’s a revenue survival problem.

The Silent Mistakes That Trigger Audits

Most OB-GYN practices don’t get audited because of fraud.
They get audited because of patterns payers don’t like.

The most common triggers include:

1. Incorrect Use of Global OB Packages

Global OB billing is one of the most misunderstood areas in women’s health. Small inconsistencies—like when services are carved out or billed separately—create patterns that algorithms flag long before humans get involved.

2. Missing or Misused Modifiers

Modifiers such as -25 and -59 are heavily scrutinized in OB-GYN billing. Even when clinically justified, inconsistent documentation or over-reliance can trigger post-payment reviews.

3. Weak Documentation for E/M + Procedures

E/M services billed alongside procedures must clearly demonstrate separate and distinct work. Many charts meet clinical standards—but not audit standards.

4. No Post-Payment Monitoring

Most practices focus entirely on getting claims paid. Very few review what happens after payment. Payers do. That imbalance is where risk grows.

Your in-house billing team usually won’t catch these issues—not because they aren’t capable, but because they’re trained to get claims paid, not to think like auditors.

The Most Dangerous Assumption in OB-GYN Billing

“If our claims are paid, we’re compliant.”

That assumption is exactly what payers rely on.

Paid claims are not proof of safety.
They are audit targets.

Compliance is determined months later—using rules, interpretations, and documentation standards that weren’t visible when the claim was submitted.

What Happens When an Audit Hits

When an audit notice arrives:

  • Staff scrambles to pull old charts

  • Cash flow slows due to offsets

  • Appeals are rushed under pressure

  • Recoupments stack up quarter after quarter

Most practices don’t lose revenue because of audits.
They lose revenue because they were unprepared.

Preparation—not reaction—is the difference between a manageable review and a financial disruption.

The Practices That Avoid This Don’t “Get Lucky”

Smart OB-GYN practices don’t wait for payers to tell them there’s a problem.

They run post-payment audit risk reviews to identify:

  • Billing patterns payers flag

  • CPT and modifier combinations that raise risk

  • Documentation gaps before they’re weaponized

  • Revenue already collected that may be exposed

This is proactive protection, not reactive cleanup.

Where MBC Comes In

MBC works specifically with OB-GYN practices to:

  • Identify audit-triggering billing patterns

  • Correct high-risk CPT and modifier usage

  • Reduce recoupment exposure before payers act

  • Protect revenue that’s already been collected

This is not generic billing advice.
This is OB-GYN-specific audit risk protection built around how payers actually review claims.

Location: United States

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