What To Do When a Payer Audits You

When a payer audits you the first thing to do is respond to the audit. Do not ignore it; it won’t go away. In the initial stage of the audit, they will probably ask you to send them your notes on approximately 5-10 patients. Either have a health care attorney or yourself send exactly what they want in a timely fashion. Delaying, or not sending the notes, might lead the insurance carrier to think that you are hiding something.

Send nothing more and nothing less than what they ask for.

  • Do not add or alter your notes or records in any way. It is easier to defend someone without a service written down next to the date than to defend a doctor who has altered his or her notes.
  • Never send originals!! Remember, the carrier has a legal right to review copies of the notes, not the originals, unless your contract states otherwise.
  • Send your notes by certified mail, return receipt requested, to ensure that the carrier has received it and to prove that you sent it.
  • Failure to send your notes could lead to a subpoena, which may hurt your case in the long run.
  • Make sure that you only send them the notes pertaining to the specific time frame that is being audited.
  • Do not use the excuse that the patient’s files were lost in a fire, flood or other calamity unless you can prove it.
  • Once you have sent the requested notes, there is nothing more to do but go back to practicing.
  • If the insurance company or Medicare finds that all your documentation is in order, the case will most probably be closed. If they do find a reason to pursue the investigation, they might ask you to call them to set up an on-site appointment so that they can continue their audit or just ask for more files. Again, do not ignore this request!
  • If you haven’t already, this is when hiring a health care attorney to represent you is recommended. This shows that you are not going to take the matter lightly. Legal counsel will request two sets of notes: one for them, and another one for the certified coder who will review your notes. Keep in mind that if you do not hire a health care attorney, anyone reviewing your notes could be subpoenaed to testify against you.

    Many times the insurance company will send a questionnaire to the patient regarding the services that were provided, who performed them and if there were any special financial arrangements or discounts made. Do not advise the patient on how to answer these questions unless you have specifically been given permission.

    It is also recommended that you have a chiropractor who is a AAPC certified coder come into your office and bring it up to today’s standards. Doing this helps the negotiation process because the insurance carrier sees that you are taking a proactive approach to correct yourself. Most insurance companies request that as part of the settlement you implement a compliancy program.

    • If they decide to do an on-site review, if possible do not be there by yourself. Have two or three witnesses present, preferably including your health care attorney.
    • Do not volunteer any information. Only answer the questions that you are being asked.
    • Always answer the questions straight and to the point, while at the same time being polite and courteous. Take note of the questions being asked and the answers given. If you don’t know the answer it is better to say, “I don’t remember–I’ll have to get back to you” rather than make something up.
    • Do not elaborate or explain anything. On one occasion a doctor mentioned a specific technique he used which caused the insurance carrier to add $250,000 to the $600,000 reimbursement they were seeking.
    • Once the carrier has completed their audit, you need to get it out of your mind and put your energy back into your practice so that you can do what you do best–helping your patients.
    • The carrier will send you a letter indicating their findings, either dropping the investigation or explaining on what grounds they are asking for a refund and how much they believe is due.

    At this point your legal counsel will review the findings of the certified coder and compare them to the findings of the insurance carrier. If anything is found to be in your favor, your lawyer will argue those points, based on your merits, to the insurance carrier. Many times a refund is due back to the doctor because the certified coder was able to find services that were performed yet never billed. If the findings did not go in your favor, per the certified coder’s findings, then your lawyer might try to discredit the audit itself.

    Eventually, if a refund is due, your health care attorney will negotiate on your behalf the best settlement possible, with the best closure and release contract implemented.

    From the time you receive notice of the carrier’s claims until the time of the final settlement, the insurance company might deduct a percentage of payments for ongoing visits. They might also block reimbursements on all of the patients whom they insure. This may or may not be legal, depending on your contractual agreement and on the law of the state in which you practice.

    The state dictates how far back the insurance carrier can go. Keep in mind that if the carrier suspects fraud they might be able to go back even further than the normal state limitations.

    If the insurance carrier does ask you for a refund, it may not be for only the patients audited, it could be for all those whom they insure. This will be calculated on a percentage basis, also known as extrapolation. If money is due back, do not immediately send them a check for the full amount requested. If you do, it could indicate that you are an easy mark, encouraging them to come back at you again.

    Do not go it alone!! Remember, the carrier has their experts, their attorneys, and they have you in their sights. You need your team of experts as well!

    By David Pinkus, DC, CPC, MCS-P, CBCS; Jeff Randolph, Esq., ANJC Legal Counsel; and Jack Beige, DC, JD, Attorney at Law