Third Party Payer Audits in Illinois
Illinois Insurance Audit Defense -
Blue Cross Blue Shield of Illinois, UnitedHealthcare, Cigna, and Aetna
Post payment audits are a fact of life in today’s health care system. Third party payers use post payment reviews to identify and recover overpayments made to providers participating in their networks. In general, an overpayment occurs when services are incorrectly coded, not properly documented, not covered by the payer’s medical policy, not covered by the terms of the patient’s benefits policy, or are determined by the payer to not be medically necessary. Each payer has their own audit, refund, and appeal procedures. While some payers are more aggressive than others in their auditing procedures and tactics, all post payment audits create a financial risk to the health care provider. Fortunately, with the proper preparation and response, a provider’s financial exposure can be minimized.
Understand Your Rights and Responsibilities
If you are a participating provider with a commercial payer, you will have signed a participation agreement that describes your rights and responsibilities in medical record reviews and when the payer identifies overpayments. Most participating provider agreements give the payer the right to review records maintained by the provider (onsite or otherwise) for a number of purposes, including quality improvement, peer review activities, medical necessity reviews, and billing and claims payment. Any questions about your rights and responsibilities under the participating provider agreement should be directed to a health care attorney knowledgeable in payer-provider contract relations.
Responding to Medical Records Requests
Upon receipt of a medical records request from a third party payer, it is important that you understand that nature and scope of the review, including the types of services at issue and the dates of service in question. Most request letters will identify a time frame for sending requested medical records to the payer. While it is important to respond to records requests in a timely manner, it is equally as important to make sure your response is complete, as you may not be given an opportunity to supplement your initial record production. When a large number of records have been requested, it may be necessary to request a reasonable extension of time to comply with the records request.
After requested records have been submitted to the payer, the provider may be invited to a meeting with representatives of the payer to answer questions about the services reviewed or discuss any issues that have been identified. Payer-provider meetings should be taken seriously as they may be the only opportunity a provider has to answer or clarify payer questions and/or to educate the payer about his or her services.
Refund Demand Letters
After the payer reviews all the information a provider submits, they will send a letter with the results of the review. This may include a demand to repay any overpayments identified through he review. The demand letter will generally set forth the basis for the audit determination, with citation to relevant policies and other supporting documentation. The letter also will describe your rights to challenge the results of the audit, including any appeal rights. In almost all cases, a provider should appeal the payer’s overpayment determination. Even if the payer does not ultimately revise their overpayment determination, an appeal is important because it lays the foundation for the provider’s defense in any subsequent dispute resolution procedures.
In recent years, payers have increasingly used pre-payment review as a tool stop perceived, consistent overpayments to providers. Pre-payment review is an administrative and financial nuisance for providers. Typically, it results in an additional documentation request from the payer for every service subject to the review. After the provider submits the requested documentation, the payer is supposed to review the documentation and either pay or deny the claim. Unfortunately, for most providers, pre-payment review often results in a large percentage of claim denials due to lack of direction from the payer or a lack of understanding by the provider of the basis or cause of the review. Complicating this issue further is the fact that not all payers clearly define or articulate the rights of providers subject to pre-payment review. A provider must act quickly and strategically in response to a pre-payment review notice, including seeking advice and counsel of an experienced health care attorney and possibly outside consultants in medical coding and documentation.
The attorneys at Goldberg Law Group deliver third party payer audit defense to doctors, chiropractors, physical therapists, clinical laboratories, and other health care providers and suppliers. We routinely advise and assist clients through the process of pre and post payment reviews conducted by the Special Investigations Department of Blue Cross Blue Shield of Illinois, and by post-payment review units of UnitedHealthcare, Cigna and Aetna. Through years of experience, we have developed a unique approach that is designed to help clients navigate third party payer audits in an efficient and cost-effective manner, incorporating the expertise of medical coding and documentation consultants where necessary.
For more information about Goldberg Law Group’s Illinois insurance audit defense, contact Michael K. Goldberg or Jenna E. Milaeger at 312-930-5600
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