Understanding Post-Payment Audits in Healthcare
Post-payment audits are a crucial aspect of the healthcare industry aimed at preventing fraud and abuse within the payment system. Healthcare providers routinely undergo these audits to ensure proper billing, coding, and documentation.
Understanding post-payment audits is essential for healthcare professionals and entities to avoid:
- Financial penalties
- Overpayment demands
- Potential license revocation.
In this guide, we’ll delve into the key aspects of post-payment audits and how to navigate them effectively.
What is a Post-Payment audit?
A post-payment audit, also known as a post-bill audit, is a systematic process employed by health insurance payers to monitor the billing, coding, and documentation practices of healthcare providers. The primary objectives of these audits are:
- Fraud Prevention: To safeguard the healthcare payment system against fraudulent activities.
- Overpayment Identification: To detect and rectify instances of overpayments.
- Compliance Assurance: To ensure that providers adhere to payer policies and regulatory requirements.
Why Providers Face Post-Payment Audits:
Providers who fail to bill or code claims properly will be held responsible and are required to pay back all the payments they received, and could face additional fines or license revocation, among other sanctions.
Audits can be conducted on any provider that receives payments. One of the most common processes that insurers utilize is the post-payment audit, also known as a post-bill audit. This generally involves the insurer requesting medical records from the provider to compare with the claims previously submitted and paid.
If there are deficiencies in the documentation or the insurer’s coverage requirements aren’t met, an overpayment demand will be calculated and requested from the provider.
What Triggers a Post-Payment Audit?
Post-payment audits are typically initiated in the following ways:
- Provider Profiling: Health insurance payers employ data analysis and profiling techniques to identify billing irregularities and outliers among providers.
- Complaints: Audits can also be triggered by complaints from patients or employees regarding a provider’s billing practices.
How can a post-payment audit be avoided?
All licensed practitioners and physicians should invest time and resources into billing, coding, and documentation compliance. Although anyone is subject to post-payment audits, by proactively learning the appropriate use of codes and abiding by documentation requirements and policy nuances, practices can be more prepared to successfully withstand a post-payment audit.
Nicholson & Eastin, LLP’s Expertise:
The attorneys at Nicholson & Eastin, LLP represent and defend providers and suppliers in all types of Medicare, Medicaid, and other third-party payer audits, appeals, and controversies. We have the knowledge and experience to assist providers and suppliers in responding to audit requests, as well as to successfully appeal any improperly denied claims. Please do not hesitate to contact us to discuss your particular situation.