Health Insurance Audits

In this era where "cost containment” is the watchword in the health insurance business, health plans increasingly use the retrospective claims audit to assess whether they believe they have made overpayments to a physician. If you receive regular reimbursement from third-party payors in your chiropractic practice, you may well be the subject of one of these reviews at some point.

A retrospective audit consists of a health plan’s review of its previously paid claims to a physician practice. The initial phase of the review often takes place within the health plan organization without notice to the physician. If the company determines that it has made overpayments, it will then send the physician written notification. I have also seen cases where the health plan notifies the physician that it is conducting a "routine” audit of cases using certain CPT® codes and requests that the physician produce patient records in cases where that code was used. I would not, of course, consider any of these notices or audits "routine.” It can be a burdensome and disruptive process requiring the pulling of files, large volumes of photocopying and preparation of detailed responses to the health care plan. Audits should be handled carefully, because the provider may be asked to make repayment of a substantial amount of money for services already provided over a period of years. Depending on the dollar amount or the scope of the audit, it is wise to have counsel assist you – obviously, the larger the amounts or the longer the period under review, the more advisable it is to retain an attorney.