Our Monitor Mondays broadcast last Monday shed fresh light on commercial auditing.

Although private insurance audits used to be rare, but over the last few years, they seem to be on the increase, reports healthcare attorney David Glaser with the law firm of Fredrikson & Byron.  “The initial contact from a private insurer may ask you to submit written records or it may include a request for a site visit, “ he tells RACmonitor.

“The first thing you want to do is review any contract you have with the payer and determine whether it allows the audit,” Glaser says.  “You will also want to review state law, since some states have laws that limit an insurer’s ability to audit.” 

Glaser offers an example, noting that many states recently passed laws limiting the time period for which insurers may audit pharmacy records. 

“If you don’t have a contract with the insurer, it is not clear that the insurer has a right to compel you to produce documents,” Glaser cautions.  “The bottom line is that before producing documents, you will want to consider whether you are required to produce the records.  You may opt to submit records even if there is not a clear legal right for the insurer to get them, but you should carefully consider your options.” 

Glaser advises that it is “a bit easier” if you were to respond to a mail request and he offers three points to stress when you do so.  “First, make sure you keep a copy of exactly what you send in,” advises Glaser.  “You might think that since you have a copy of the electronic record, it is wasteful to make a complete copy.  But you want to know EXACTLY what was submitted.”

Glaser explains that in an audit it is quite common to have questions about whether some lab or diagnostic test was sent.   And, he stresses, the only way you will know is if you have a complete copy of what you submitted.

“Second, number the pages,” Glaser says.  “Referring to excerpts in a record can be very difficult without page numbers.  Finally, you need to decide to send only exactly what is requested or to send other info that might be helpful.” 

Glaser points out that, for example, if the request mentions a particular procedure, do you want to send the record from the visit at which the physician decided the procedure was necessary?  “Reasonable people could differ, but I general err on the side of being more inclusive,” Glaser concludes.

NEXT INSTALLMENT: The Care and Feeding of Onsite Auditors


Share This Article