What are retrospective audits?
Once insurance claims are settled, physicians' practices hope, and probably assume, that the claims won't be revisited. The American Medical Association (AMA) and American Academy of Neurology presented a cautionary report, updated in 2010, warning physicians that insurers may be taking a backward look at previously settled transactions from even years earlier.
A Retrospective Audit is when insurers review past claims they think were overpaid and seek repayment for some of the amount. The audits may reveal legitimate discrepancies at times, but audit findings are not always appropriate and physicians are entitled to certain rights and knowledge of the accusations and processes to follow.
How might you be at risk?
Insurers are checking for a variety of reasons to run a retrospective audit on a physician's practice. Aside from randomly conducted audits, here are a few specific reasons why insurers might look into your practice:
High service volume
To insurers, a physician practice with high service volume may imply over-use of reimbursable services.
Coding issues
When insurers spot repeated use of the same evaluation and management services, for complex and varying cases, they assume inaccurate reporting and violation of Current Procedural Terminology (CPT) codes set forth by the AMA.
Modifiers
The CPT modifier 25 is used to report an evaluation and management service on a day that the same physician provided another service to the patient. Insurers become suspicious when a practice frequently reports a modifier 25.
Recovery Audit Contractors
Recovery audit contractors (RAC's) help determine improper payments to physicians. Each physician practice should review its RAC's website to stay current on the issues that the RAC's will focus their audits.
What should you do if selected for an audit?
Practice your right to be informed! Make important inquiries about the insurer conducting the audit and the process involved. Ask state and county medical associations and national medical specialty societies. Ask the American Medical Association and any government agencies that regulate insurance. These organizations will be able to provide valuable information and will also be alerted that insurers are conducting possible unfair practices against physicians.
Additionally, reviewing current guild lines and codes while comparing them with your current billing and coding practices is important to prove patterns of compliance, and therefore, to help validate claims billed to the insurer. Reviewing the contract that the practice holds with the insurer is also a helpful preparation for an audit. It may yield protections for the practice against the insurer's accusations.
If the health insurer is noncompliant with state laws, in your particular case and has had a pattern of noncompliance in the past, the best step forward is to obtain legal counsel for following necessary litigation. Physicians' practices should be aware of the risks before they are selected for an audit, but if the insurer has already chosen you, there are resources to utilize and steps to take for protection.
Ashley is a guest blogger who specializes in health insurance audit and has a passion for health insurance litigation.
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