We have noticed significantly increased post-payment review audit activities on behalf of Highmark and HGSAdministrators, the Medicare side of Highmark.
When records are requested, it is critical that you do not respond cavalierly. The records you initially supply will be used to determine whether you will be subject to a refund request and further review.
If you have not been involved in this type of audit activity before, you should experienced counsel to assist you with your response. The potential for extrapolated refund requests is a serious threat.
We have noticed significantly increased post-payment review audit activities on behalf of Highmark and HGSAdministrators, the Medicare side of Highmark.
Audit requests are typically presaged by a letter (ULTRA Report) advising that you are an intensity outlier, i.e., an over-utilization in a particular service or group of services. If you received this notice, you should immediately review the letter to assure that you are correctly characterized with regard to specialty, because your intensity is compared to the use of those same procedures by other physicians in your specialty and to assess the margin by which you are exceeding your peers. You then need to review your billing practices in those procedures in order to either be prepared to defend your practices or to revise that practice, where appropriate. Some ten practitioners will always be the top ten providers, but if you exceed your peer norms by significant factors, this is usually a good warning sign about a potential audit.
The audit itself starts with a request for medical records for approximately 25 to 35 patients or services. The procedure is to review these medical records internally and generate an analysis that either supports your utilization or determines that the services were not covered for a variety of reasons, i.e., medical necessity, failure to abide by policies such as mandatory surgical second opinions or some other cause. You will then be invited to submit additional information and that information can be submitted to an outside reviewer.
When records are requested, it is critical that you do not respond cavalierly. The records you initially supply will be used to determine whether you will be subject to a refund request and further review. This is your first and best opportunity to present all of the information necessary to support the intensity and billing for the services you provided. You should provide as much information as possible, a thorough explanation of why the services were provided and billed appropriately, and even engage in outside reviewer to support your position if you believe this is necessary.
If you have not been involved in this type of audit activity before, you should experienced counsel to assist you with your response. The potential for extrapolated refund requests is a serious threat. Medicare and Highmark are authorized to use the sample you have provided to generate refund requests covering the three year period prior to the services. For example, if 30 services are reviewed, and it is determined that 10 of those services were unnecessary, then it is possible that you will be subject to a refund request for 33% of all of the money that was paid for you for those services for the prior three years. Depending upon the volume of your services, these numbers add up very quickly. An easy way to evaluate your risk is to determine the number the number of services that are being reviewed and the number of services billed during the review period. If this is one of your high volume services, the refund request could present a serious financial threat, and you should deal with this as such from the very beginning of the audit.
