Facing Insurance Audits as Out of Network Provider

According to the 2021 Milliman Report, more and more providers has preferred to provide healthcare services as Out of Network Provider provider. This Out of Network Provider utilization is much higher for mental health services than for medical or surgical services. Relaxed telehealth policies during the COVID-19 pandemic have offered more access to Out of Network Provider providers. Since the auditing of patient records has been increasing for in-network providers, it’s no surprise that insurance companies are scrutinizing Out of Network Provider claims more frequently as well. Even if you are not in-network with the patient’s insurance carrier or you do not accept insurance at all, you could still receive a request from the patient’s insurance company to review their records. 

If the patient submits a claim to the insurance company, then the company may verify that the services are being provided fulfill the criteria of ‘medical necessity or not. While you may not have a contract with the insurer, your patient does. Denying access to records may have serious ramifications for both your patient and you, so it’s important for you and your patient to understand potential consequences. In this article, we discussed basic tips on facing such insurance audits as an out-of-network provider

Basic Tips on Facing Insurance Audits as an Out Of Network Provider

Understand Purpose of Audit

Insurance companies may contact you under the Risk Adjustment Audit process. They may want to conduct a review for medical necessity or proper coding. An inquiry into issues of fraud, waste, and abuse is often signaled by an audit letter from the company’s Special Investigations Unit (SIU). But recently, some companies have sent more mundane audit requests, like medical necessity audits, from the SIU department. If the nature of the request is not clear in the letter, contact the company for guidance

Obtain Patient’s Consent

You must obtain the patient’s consent to provide access to information in the records. Failure to comply with insurance company audit requests may result in the claim denial, or future reimbursement being denied, or demands for repayment of claims already paid by the insurer. There may be times when patients object to you responding to an audit. If they refuse at the beginning, you may want to refer them to another provider. Or you can discuss the level of detail to record which may alleviate their concerns about overly sensitive information being shared with insurers. Another option would be to suggest that the patient self-pay and not submit claims for reimbursement. A patient may have a change of heart after you have already been paid and direct you to refuse to provide records to the insurance company, even after you have reminded them of the potential consequences. In that scenario, we recommend that you honor the patient’s request, or contact your malpractice carrier for further consultation. 

Understand Record-keeping Requirements

Understanding the policies of the patient’s insurance company as the company/auditor may determine medical necessity through the lens of the insurer’s documentation standards. They typically require documentation to support medical necessity, such as patient name and date of birth; dates of service; start and stop times for face-to-face interaction; diagnosis, symptoms, and status; treatment plan; goals and response to treatment. You can easily access policies through the insurance company’s website. Under HIPAA, insurance companies are only entitled to the minimum necessary information to support the reason for the audit. You may also want to adjust your record-keeping practice in anticipation of a future request.

The best way to stay prepared for insurance audits is to submit every claim carefully and maintain documentation to support medical necessity. For providers, it might not be possible to pay attention to revenue cycle functions at every claim level, as most of their time is utilized inpatient care. You can always take help from expert medical billing companies like MedicalBillersandCoders (MBC). We provide complete medical billing services including but not limited to charge entry, payment posting, accounts receivable management, denial handling, eligibility, and benefits verification, and provider credentialing. To know how we can add value to your medical billing operations, contact us at info@medicalbillersandcoders.com/ 888-357-3226

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