Blue Cross Blue Shield Audits

Third party payer audits are an understood part of medical practice in an era of increased payment and compliance oversight. One such payer, Blue Cross Blue Shield, routinely audits practices to ensure that it has not made overpayments to providers and that proper billing practices are followed. Here is an in-depth guide to Blue Cross Blue Shield audits.

Blue Cross Blue Shield Auditing healthcare practice for billing compliance

Like any third party payer, Blue Cross Blue Shield takes every opportunity to ensure it is properly paying service providers for covered services. As such, it periodically audits healthcare practices for billing compliance. Any post-payment audit can pose serious financial risk to providers, as should any discrepancies or issues be found, there is risk not only of financial penalty, but also, in more severe cases, risk of civil and criminal liability. 

There are many different facets to every audit; BCBS might look at:

• Coding

• Billing

• Medical necessity of services and procedures

• Documentation

• Policy coverage of payer

• Policy coverage of patient

The best defense for such audits is securing legal representation as early as possible to ensure adequate preparation and documentation for every audit.

Goldberg's Experience in Healthcare Fraud

Our team of experienced lawyers provides insurance audit defense services from start to finish and will help your practice mount the best BCBS audit defense it can. Our years of experience and casework proves us well prepared for all third party payer audits and we understand the specifics of BCBS audits as well as proactive steps to take to ensure compliance. We also have coding and documentation specialists available to consult should the need arise.

Common issues in Blue Cross Blue Shield Audits

BCBS audits often lead to discovery of documentation, coding, and compliance issues within a healthcare provider’s own practice. Common issues include:

• Improper Coding - Proper and consistent medical coding that follows guidelines is paramount in ensuring proper payment for each procedure is issued. Should coding discrepancies be detected, this could result in a payment reversal, posing financial risk to your institution.

• Upcoding - Upcoding, or coding for a higher or more complicated services or procedures than performed, is fraud and can result in financial penalties.

• Improper or incomplete documentation - Adequate documentation is necessary not just to ensure quality of care but also for assessing the medical necessity of services and procedures performed. Inadequate documentation may result in recoupment of payment, financial penalties, or contract termination.

• Lack of Medical Necessity - It may be determined that a procedure performed was not medically necessary, which would result in services being denied for coverage.

• Coverage Issues - Procedures performed might not be covered by BCBS writ large or may not be covered under the patient’s policy.

While practices do have rights in an audit, it is important to fully document and correctly code all procedures to present a pre-emptive defense to audits. 

How to Be Prepared for an Audit

As mentioned earlier, audits conducted under suspicion of overpayment or even routine audits can pose severe financial risk to practices, as well as potential civil and criminal liability. That being said, besides securing legal representation, there are many steps you can take to better prepare for an audit:

• Conduct regular internal audits to identify and correct billing errors

• Maintain accurate and detailed documentation for all services rendered

• Stay up to date with coding and billing guidelines

• Educate staff on proper billing practices and compliance requirements

• Consider hiring an external auditor to conduct periodic audits for an unbiased review

Frequently Asked Questions

Why is Blue Cross Blue Shield auditing your healthcare practice?

Blue Cross Blue Shield routinely audits providers to ensure no overpayment has been made for services rendered. Additionally, should there be consistent documentation or coding issues, a greater or lesser than normal amount billed, patient complaints, or even tips from employees or competitors, this may also trigger an audit.

What are your rights during an audit?

All providers have the right to legal representation and the right to mount a comprehensive audit defense. Additionally, should the outcome be unfavorable, you have the right to review findings as well as appeal the decision.

What are the risks of an audit?

Audits pose a financial risk primarily: should overpayment be detected, the overpayment will need to be paid back to BCBS or may be recouped involuntarily by BCBS. Additionally, more serious compliance issues can result in civil or criminal liability, federal investigation, and/or potential removal from the provider list at BCBS. 

Can you contest an unfavorable outcome to an Blue Cross Blue Shield audit?

Yes, providers have the right to appeal audit findings and present additional information and documentation to support their billing practices. Providers may also have the right to avail themselves of alternative dispute resolution procedures such as mediation or arbitration if internal appeals prove unsuccessful.

Contact Us for Audit Guidance and Help

Understanding the potential ramifications and preparing accordingly is not just a matter of due diligence; it's essential for the continued operation and reputation of your practice. With Goldberg Law Group's seasoned team offering comprehensive insurance audit defense services, providers have access to a wealth of experience in navigating the complexities of BCBS audits. Contact us for expert guidance and you can explain your concerns to our lawyers servicing the states of Illinois and Arizona.