Medical Billing Forum

Coding => Coding => Topic started by: jennifer8055 on July 16, 2015, 03:49:42 PM

Title: insurance chart audit requests.....?!?!??!!?
Post by: jennifer8055 on July 16, 2015, 03:49:42 PM
Has anyone else received a ridiculous amount of chart audit/review request from insurance companies?

I can understand sending requests for chart audits every month - within reason - 25 or so.  Currently, we have requests from two insurance companies that are beyond excessive.

Humana   150 claims
United Healthcare 262 claims

We are a completely electronic office and this would be a MASSIVE amount of paper wasted for everything the insurance companies are wanting.  Why do we have to waste time, resources and money doing this?  I know deep down in the contract it states we have to comply, but this crazy.  I know some offices just let a representative from the company come in an access their EHR system, but we don't have the space for someone to do this and be able to be supervised by someone from our office to make sure they are only getting what they need.

Curious if anyone else is having the same issues.

Thanks -
Jennifer  ???
Title: Re: insurance chart audit requests.....?!?!??!!?
Post by: PMRNC on July 18, 2015, 09:24:25 PM
I have worked for 3 of the top 5 carriers. I can tell you if you are receiving that many chart audit's your office is red flagged. Normally a random audit is 1-10 charts. What your claiming is beyond a random audit which means they are looking at something specific. My advice is to make sure all of your ducks are in row. MAKE sure all audit trails are in place. There's not too much you can do without rocking the boat at this point unless your prepared to get out of the networks.  I would also suggest your practice hire an independent auditor to come in and audit so you have legal backing. This isn't anything to play with.. the amount of chart audit's your claiming strongly suggests the practice is under a "red" flag.
Title: Re: insurance chart audit requests.....?!?!??!!?
Post by: dekenn on July 20, 2015, 10:35:04 AM
It may be a red flag, but more likely, I think it's just the medicare advantage plans. Every year, they request all the chart notes for all their insureds that you have seen in a certain time frame. They go over these notes to see if there is any other "chronic" diagnosis that would make them eligible to receive more money from Medicare for the coverage of these patients. Unfortunately, they all do it at the same time too. Right now, I have three audit requests, all 30 to 40 charts each, requesting notes from January 1, 2014 to present.
Title: Re: insurance chart audit requests.....?!?!??!!?
Post by: PMRNC on July 20, 2015, 12:42:07 PM
Take a look at this.. It's for risk analysis performed by Medicare on Advantage plans due to upcoding..these technically are not audit's. Not sure this helps you but still they say between 10-30 charts.. so again what they are requesting from you is very excessive IMHO.

I also would suggest getting a compliance officer to manage and maintain the practices compliance program so that you can be sure you have a system in place to identify any compliance risks that might exist.

I don't know any way around this but to give them what they want as you are obligated to do under contract and by law since CMS does oversee and pay Advantage plans (again, based on risk analysis).

I would take a look at these requests and make a few phone calls to also inquire as to the high volume of requests your getting.
Title: Re: insurance chart audit requests.....?!?!??!!?
Post by: kristin on July 20, 2015, 07:43:10 PM
I go through the Medicare Advantage risk analysis chart review every year also, and I have found that the amount of charts requested is strictly a matter of how many patients have that insurance. In other words, they ask for everyone with it. Two years ago, for example, it was maybe 4 people for UHC MA plan. Then our state had all all retirees from the state switch to that plan, and the number of patients with it now is over 40.