Insurance audits have
become much more prevalent. We have seen many audits performed by Insurance
companies, including Medicare, Medicaid, Blue Cross, VSP as well as other payers.
Most penalties are
between $150,000 and $225,000 though many penalties have exceeded $1,000,000!
have successfully appealed many negative insurance audits, throughout the
country and for all payers.
Some practices were
also removed from the insurance companiesí panels. We have successfully defended doctors
and had them reinstated.
For the most part these
audits were against practices who were following what they thought were good
coding, billing and documentation processes. Unfortunately what the
Insurance Auditors are looking for is not a good medical examination. They
are only looking for technical components.
There are many factors
that cause practices to fail an insurance audit. These are described it the
Chances of Being Audited".
first step in defending a doctor or practice from a negative audit, is to
thoroughly review the insurance auditor's report. We typically find mistakes by the
auditor that resulted in much higher penalties. We have appealed the
findings and in most cases significantly reduced the penalty.
cases, the doctors have first turned to their lawyers. However, the lawyers
are not aware of which procedures are supported by which diagnoses and miss
significant auditor mistakes. In several cases practices were recommended
to settle and when we reviewed the auditors findings we challenged new areas
and significantly reduced the proposed settlement amount.
The most successful approach
is to first review the auditor's findings. We then prepare a detailed
report identifying incorrect findings and conclusions by the auditor.
We also recommend how much the penalty should be reduced or even eliminated.
At this point we work with the
practice's attorney (or recommend one) to file the appeal. We work
throughout the appeal process and hearings to negotiate a beneficial result
for the practice.