What are post payment audits?
A post-payment audit is when an insurance company looks over your account and the claims that they have paid to you on behalf of the treatment you’ve given to patients, and then they say “Oops, we’ve made a mistake. We want money back.”
When they do that they could be asking for as little as a couple thousand dollars or as much as millions of dollars. This could possibly destroy a practice and you want to be very careful if you’re dealing with the issue of a post payment audit. Typically it starts with a simple letter to your clinic saying “Hey, we want to look over a few patients.
Please send us your records and your bills.” Insurance companies generally come to this by running a query in their computer system looking for outliers. They will look for practitioners that maybe give a bunch of services at one time, or look at the total amount of the bill, or just look for something unusual about your pattern of claims submission.
That is what draws their attention. Then they’ll send a letter that does not appear to be alarming.
When you get a letter like that it’s a good idea to get a really good healthcare attorney in your corner as soon as possible because as soon as you start responding, as soon as you start pulling up patient records, as soon as you start answering their questions and providing them information, you are creating a record that you will have trouble backing away from later on.
A good healthcare attorney will look over everything and they will be able to tell you where you’ve got some problems. They will be able to help you become more compliant and move in the right direction; they will help you draft a good response letter to the insurance company and provide you the greatest chance of success.
Often times when you’re in the situation, you’re dealing with questions like:
- Is this going to generate a board complaint?
- How much are these attorney’s fees going to cost me?
- Are they going to come after me for tens of thousands or hundreds of thousands of dollars?
- How is this going to affect my day-to-day practice with my patients?
When dealing with a post payment audit you have to prioritize these issues and decide which one is most important for you.
Often times there is another question, “Are they going to kick me out of network?” Some of you may have the response, “Good riddance; I’d like to get rid of them.” Others will think, “Well, eighty percent of my practice depends on that insurance company so I want to have a good relationship with them.”
You will have to weigh all of these factors and decide which is the most important for you and your practice.
Post payment audits are a complex matter so the best thing you can do is to get a good, competent healthcare attorney to take good care of you, to guide you through the process, and to provide you the best possible outcome.
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