United HealthCare Audits

United HealthCare (UHC) is one of the largest third party payers in the United States. Like every other third party payer, it routinely conducts audits to ensure payment is appropriate and for covered services. Like all payers, UHC also audits providers when various “red flags” appear in documentation, billing, or coding. In this era of increased payment compliance oversight, third party payer audits are a fact of life: here’s our guide to UHC audits. 

United HealthCare Auditing healthcare practice for billing compliance

While UHC can audit providers at random, many audits are triggered by targeted reviews of billing patterns which suggest that a provider is an “outlier” or is billing properly. Audits can pose a serious financial risk to providers, as the outcome may require repayment, financial penalties, or even civil and criminal liability, depending on the severity of the issue. 

To conduct an audit, UHC will likely look at:

• Coding

• Billing

• Medical Necessity of Procedures

• Documentation

• Policy coverage of payer

• Policy coverage of patient

It is important to secure legal representation once an audit is triggered to ensure a comprehensive defense and proper documentation is collected for submission to the payor. 

Goldberg Law Group's Experience in Healthcare Fraud

Presenting a strong defense for UHC audits is incredibly important given the potential consequences, and Goldberg Law Group’s team of healthcare lawyers have years of experience in third party payer audit defense. We know the ins and outs of UHC audits, how to ensure pre-emptive compliance, and have coding and documentation experts available to ensure your UHC audit defense is airtight.

Common issues that lead to United HealthCare Audit Recoupments

UHC audits of providers are primarily focused on documentation, coding, and billing practices. Here are some of the most common issues: 

• Improper Coding - All medical services and procedures must be coded correctly. Services and procedures that are coded incorrectly may be denied or payment for those services may be recouped.

• Upcoding - Coding a service or procedure as something that is “higher” or more complicated than it is, is a type of medical fraud and could result in recoupment or civil or criminal penalties. 

• Improper or incomplete documentation - Documentation is important not just for compliance and billing purposes, but also for patients and providers to make informed treatment decisions. When documentation is incomplete or missing required elements, payors will deny or recoup payment for services.

• Lack of Medical Necessity - If a service or procedure is deemed not medically necessary, payment for the procedure will be denied because it is not covered.

• Coverage Issues - If a service or procedure is not covered under a patient’s insurance policy or UHC’s clinical and coverage guidelines, payment may be denied or reversed.

It is important to mount the best defense by committing to best practices at all times and ensure that all documentation is complete and compliant with all applicable guidelines.

How to Be Prepared for an Audit

As mentioned earlier, all third party payer audits, whether routine or not, pose a financial risk to providers and practices. Such audits may also create a risk of civil and criminal liability. There are several steps providers can take before even securing legal representation - or receiving notice of 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 of billing and documentation for an unbiased review

H2: Frequently Asked Questions

Why is United HealthCare auditing your healthcare practice?

UHC audits providers to ensure that payments made conform to clinical policies and coverage guidelines and to investigate suspicious billing activity, such as documentation or coding discrepancies, which may indicate fraud, waste or abuse. Complaints from patients and other providers 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 in the case of UHC audits. Additionally, you also have the right to appeal, should the outcome of the audit be unfavorable.

What are the risks of an audit?

Should overpayment be identified, UHC may recoup or request voluntary repayment from the provider. Additionally, depending on the severity of the issues identified in the audit, providers may be referred for civil and/or criminal investigation and/or terminated from the provider network at UHC. 

Can you contest an unfavorable outcome to an United HealthCare audit?

Yes, providers have the right to appeal audit findings and present additional documentation to support services and procedures performed as well as their billing and documentation practices.

Contact Us for Audit Assistance

Navigating the complexities of UHC audits requires a team of professionals with knowledge and experience in third party payer audit defense. Effective legal representation is important to ensure that all areas of liability/risk are considered and the strongest defense mounted. For assistance and guidance through every step of the audit process, consider utilizing our insurance audit defense services. If you're facing an audit or just have concerns about future audit activity, contact us today. Our attorneys serve providers in Illinois and Arizona.