Situation:

Your medical practice receives a letter from one of the practice’s contracted- health insurers. The letter requests a certain subset of patient records, which your practice supplies.

After an audit of those records, the health insurer sends a letter that sets forth the audit findings and demands the return of a certain amount of funds considered to be an overpayment by the health insurer to your practice. Do you advise your practice to pay the demanded overpayment?

Issues:

Financial loss; fraud; referral to other reimbursement or fraud-fighting entities.

Solution:

You should “cooperate” with the audit, but this does not necessarily mean paying the demanded amount of overpayment immediately. You should consult legal counsel and do your own “audit.”

Often, the audit has mistakes that would result in the practice returning more funds than it should. Allegations for demanding repayment might include failure to provide a record set, incomplete documentation in patient records, documentation in patient records not sufficient to support the billing code, and/or lack of physician signature, for example.

We’ve seen many times where the documentation was provided to the auditor but missed in the auditing process. In other instances, your office may not have copied all of the records, and the missing parts of the records are what can substantiate the billing code.

You need to evaluate the auditor’s findings. Cooperating with the audit means cooperating with the process so that you can do so in an amicable way. Meet the time deadlines provided by the health insurer or obtain an extension to respond to the audit. Do not be adversarial; it only makes navigating the process more difficult.

More often than not, the practice can identify errors in the audit or make a case for rejecting a conclusion reached by the auditor. Legal counsel can help and will have access to, if needed, coders and reimbursement specialists, and other experts. The result can be a significant reduction in the amount of fees returned to the health insurer.

Please contact Maggie DiCostanzo with any questions to help your medical practice successfully navigate a payor reimbursement audit.