Received Payer Request With Outsource Medical Billing

If you received a letter to your company in a plain-looking envelope you might be nervous to even open the envelope. It’s a little unsettling for a payor to ask for medical records in relation to claims already paid. It’s becoming more typical for companies to get what appears to be harmless requests for medical records from commercial and federal payers. The worst option is to not even open the letter. Medical records requests are an everyday situation, and your response can have a significant impact in the final outcome and effect on the procedure.

These requests typically are made based on data analysis provided to the payer, which indicate the service as an outlier in a particular way. Outsource Medical Billing use analytics to determine if there are any possible issues with overpayment. Unfortunately, many companies are not aware of the importance of these inquiries and the implications the inadequacy of a response may affect a future overpayment request and/or the possibility of a suspension to payments through Medicare or any commercial provider. 

Outsource Medical Billing

Outsource Medical Billing
Received Payer Request With Outsource Medical Billing

What are the triggers for an Audit?

The biggest mystery of the auditing process is the source. There is often no reason ever provided in the event that a service is selected to be audited. But, there are typical circumstances that can result in an audit, such as listed below:

Computer monitoring of patterns for practice:

The higher than average utilization of specific procedures and the presence of outlier payments are among the most frequently used audit triggers. Occasionally, third-party payers evaluate the use patterns between physicians with similar practices within the same geographic region. In addition, an audit could occur if the practice’s billing or reimbursement amounts drastically change within a short period of time. However, there may be a plausible explanation for the change in the form of purchasing a brand new device.

Patient complaints:

Patient complaints frequently prompt investigations or audits. Patients can complain to payers due to misinformation regarding their Explanation of Benefits (EOBs). For both patients and employees it is crucial to pay attention and address any concerns regarding billing.

Random Selection:

Audits are a part of the routine of healthcare, and everybody can be at risk. And even if the event that led to the audit turns out to be false (e.g. or unsubstantiated patient complaints or comparisons with the incorrect group of peers) it’s difficult to stop an audit after it’s in motion.

Know What You’re Dealing With

When you are able to regain your confidence After regaining your composure, you should verify the nature and purpose of your “audit.” Every payer that you bill has a reason to audit, and a procedure to conduct an audit, however not every request for medical records can be considered an audit. Be aware of the entity that is requesting records and what the purpose of the request is.

For instance Medicare Advantage plans conduct review of data verification, which are basically reviews of diagnosis documents to confirm billing and to find mistakes in diagnosis. They do not typically examine CPT codes. However, Comprehensive Error Rate Testing (CERT) reviews are designed to assess the Medicare contractor. However should it be discovered that a claim has been wrongly paid, the funds are returned towards the company.

What is the best way to proceed with Audit?

  • It is important to carefully plan in advance with counsel for your actions throughout the audit. A few general guidelines to be followed during the audit are:
  • The auditor is placed in an area that isn’t part of normal business activities.
  • The auditor should be provided with the complete medical records prior to the start of the audit, in order to limit requests for additional details.

There is no reason why any Outsource Medical Billing information be modified, faked or retroactively dated. Information that is already in place, such as previously dictated notes , as well as test results, can be stored within the file in accordance with standard office procedures. It could be helpful to ask for an entrance conference. Although they aren’t often requested, they could help in limiting the extent for the audit.

Choose one person in the office to be the contact person. This person should be an office manager or another person who is familiar with the billing practices of the office. Prior to the audit, the person in charge will discuss with counsel the best way to address any concerns.

Request that the auditor write his or her concerns in writing, and then let counsel look over the questions. The questionnaires given by the auditor are the same in the same way. Ask the auditor to provide you with an end-of-service conference. It’s not the right time for you to “plead your case,” instead, just to observe the auditor’s comments. An employee must be present to take note of the details that the auditor has provided.

Requests for records are handled with calmness

The doctor agrees to provide medical records upon request in the contract between the payer and the practice and also as part of the process of submitting the claim. In order to comply with this contract it is your responsibility to provide your requested medical records within the deadline specified. Send only what was required; it’s generally not an ideal idea sending more was required.

For instance, the documentation needed regarding injection administration might not be in the encounter note. It is possible that you will require additional screens in order to provide evidence to justify all the billed services. 

The records should be organized so that reviewers can easily locate the relevant information. There are many stories of people who responded to audits by an Internal Revenue Services (IRS) audit by bringing the receipts in a shoebox placed on the auditor’s desk. This isn’t a good idea for the IRS and won’t be able to work with an audit of a payer as well. Do not even think about ignoring the request. In the event of a delay, the payer has the right to cancel the payment.

What is the next time?

In a matter of months or perhaps years, the service provider will receive a notice which details the findings. Alongside stating the amount overpaid The letter will usually include an explanation of the reasons for the overpayment. Usually, the payee is required to refund this amount in 30 days. The audit document should include a list of services that the auditor inspected and their conclusion on each one. Communication that suggests a finding that there is no overpayment is very uncommon.

If you are unsure, dial for assistance

You should consider whether you want to hire an attorney. If the problem could have significant financial consequences, you should consider reviewing the records with an auditor independent of the company. Internal reviews are one of the initial steps, however getting the “outside eye” review of these documents can be extremely beneficial. Independent auditors conduct a variety of reviews for service providers. And frequently, they provide advice on appeals strategies. They can also identify problems you’re not aware of.

It’s an chance to make money

An audit, or even an information request, could be an opportunity to learn for both you and your provider. After you’ve complied with the request from the payer Conduct an internal audit and begin addressing any errors you discover and also educating your providers whenever required. If you have any questions regarding audits or you’ve been informed about one, Medcare Medical Billing Services (MSO) can assist. Contact us at +1 800-640-6409 or email us at

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