Post Payment Audits

What is a Post-Payment audit?

In order to prevent fraud and abuse within the health payment system as well as identify overpayments, health insurance payers routinely monitor the billing, coding, and documentation of healthcare providers through 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. 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?

The most common trigger for a post-payment audit is provider profiling and data mining to identify aberrant billing practices and outliers. In addition, post-payment audits can also be triggered by complaints made by patients or employees about the practice.

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.

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.


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