Physician's Practice - November 2008 - (Page 67)

CME THE LAW THIRD-PARTY AUDITS ON THE RISE B Y PA M E L A L . M O O R E , P h D WHO’S REVIEWING YOU? Arvind Cavale was confused. In spring 2008, the endocrinologist got a letter from a company called TPL2. It asked for a refund, saying Cavale had been overpaid for ofﬁce visits in 2006. The letter also gave Cavale the option of a chart review to defend his payments. Cavale didn’t know who TPL2 was. But he did know the patient whose visits were under question was insured by a Blue Shield plan, so he contacted his rep there. They didn’t know anything about it. It turned out the request was from an ex-employer of the patient’s spouse. Cavale then sent complaints to the Pennsylvania Insurance Commissioner’s ofﬁce, which refused to get involved. The state attorney general begged off as well. Finally, the Blue Shield plan asked the ex-employer to knock it off, and the matter seemed to go away. But today Cavale still isn’t happy. “I am itching for a ﬁght; I would love to squish these guys like a cockroach. It is truly beyond the capacity of any small practice to sift through this maze.” True enough words. As if your practice isn’t already crazy enough, audits seem to be on the increase across the country. Especially troubling: Audits from third parties, such as that which Cavale faced, are becoming more common. Payers LEARNING OBJECTIVES After completing this article, readers will be able to: • Recognize the risks involved in responding to a third-party audit • Plan a response to a third-party audit • Determine what to question about a payer’s policies regarding audits WWW.PHYSICIANSPRACTICE.COM are outsourcing audits to outside companies and some employers are performing their own audits as well. That raises eyebrows. While HIPAA allows the release of medical records for payment and operations, things get a little murky when you start giving employers the records of employees, even if the employer is also the employee’s payer. Plus, no one wants to facilitate a ﬁshing expedition by someone not really involved in the payer-provider relationship. It’s all fair and square, usually, but it sure can be confusing to a worried practice. Experts advise a deep breath and two simple steps: Check credentials and your contracts. CHECK CREDENTIALS “If someone walks in and says they want to audit charts, you ask, ‘OK, by what authority?’” says Jeff Hausfeld, a physician who also is managing director at FMS Financial Solutions in Washington, D.C. Keep in mind that most auditors don’t NOVEMBER 2008 | PHYSICIANS PRACTICE | 67 http://WWW.PHYSICIANSPRACTICE.COM

Table of Contents Feed for the Digital Edition of Physician's Practice - November 2008

Physician's Practice - November 2008 Contents Death of Solo Practice Just a Myth Letters HSAy What? Noteworthy Finding Lost Revenue: The Search for Billing and Coding Gold Getting More: Our Annual Physician Compensation Survey ’Tis the Season to be Neutral Ask the Experts Evaluating Paperless Labs HR in a Box? The Guide Coding Third-Party Audits on the Rise Branding the Cash-Only Practice Intra-Office Tug-of-Wars Stickin‘ Up For Yourself Classifieds Advertiser Index

Physician's Practice - November 2008

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