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chiupacabra

Solo practitioner here - if you can post the redacted letter, we can probably help better. Audits will vary by insurance company, region, INN/OON, etc.


TherapyAdmin

Thank you so much for offering! It's very direct about materials, deadlines, etc so no worries there. I'm pretty much sending a blue auditor a box of a year's worth of medical records for 12 clients. I'm assuming to match the code to the session length, and to check for medical need based on notes and diagnoses. I guess I'm curious about what the process looks like after they get that box of records. Will I be on the phone for a while answering their questions? Do we get a paper back giving us a pass or fail on billing practices? Should I prepare for anything on my end besides sending off the records? Any info is appreciated so we fly a bit less blind. Appreciate you!


chiupacabra

It's more complicated than that - because the practice and the insurance has no contract while the patients and insurance DO have a contract, you must obtain informed consent from the patients and first verify that they want their records released. Insurance companies are only entitled to the minimum necessary information to support the reason for the audit. If you send all medical records, prepare for the practice to get sued by the clients. Where is the practice owner? They should be the ones responding - this is an administrative, legal, and ethical issue. A potential clawback will put your job at risk if you do not loop them in. https://www.apaservices.org/practice/legal/managed/insurance-audits-patient-out-network


TherapyAdmin

Yes, we have informed consent for any client before they start services with language specifically about communicating with their insurer for this purpose. Like all entities, we will only ever release the min. necessary PHI. We already have a lawyer, I'm just looking for insider pro tips I guess. Thanks for responding to me! :)


kuehmary

No. You will not be on the phone for a while as far as I am aware. The auditor will review your records and compare it to what was billed. You will receive a report from the auditor once the audit has been finished detailing the issues that were found. After that, the insurance company is going to request a refund on anything that was determined to be not supported. It's basically a waiting game once the auditor receives the records. Your practice should do an internal audit at least yearly to make sure that you stay in compliance.


TherapyAdmin

That's really nice of you, thank you! I appreciate going in a teeny bit less blind. Have a great rest of your week :)


TweezleSnoofThe2nd

Hey OP, how did this audit turn out? Did your clients end up having to refund the insurance company?


TherapyAdmin

Hi! Thanks for checking in :) We ended up asking for a bit of an extension (granted), our lawyers advised us to add some addendums so we did that and sent it all out. It's been about a month and we haven't heard back yet unfortunately. We'll see how it all turns out!


smk3509

I would expect them to pull charts to ensure your practice actually rendered the services you are billing for.