Opportunity – Help an attorney and his physician specialist client navigate the appeals process for an audit that began as a fraud investigation.
Process – Coordinated a proactive approach to alleviate the identified problem in order to shift the focus of the investigation from fraud to overpayment.
Result – The carrier accepted $13,500 rather than the $151,000 requested by the fraud unit.
AHA Moment – After a brief review of the billing, we quickly identified the problem. We immediately conducted t raining to educate the provider on the proper way to bill, and determined the overpayment directly related to the review.
The Story– We helped an attorney and his physician specialist client navigate the appeals process for an audit that began as a fraud investigation. The agency, a Program Safeguard Contractor (PSC), which initially requested the records, is focused on fraud investigations. Our first task was to determine if the billing was improper and/or intentional. We quickly identified the problem as being related to coding and interviewed the physician to assess the root cause of his aberrant coding pattern. A gross mis-understanding of the code range was apparent, while intent to defraud was not. We immediately conducted training to educate the physician on the proper way to bill, and determined the overpayment directly related to the review. We then assisted the attorney in writing a letter to the agency accompanied by a check in the amount of the overpayment. The PSC denied it, but said that it would send the check to the local carrier and that we could appeal to them as well. We did, and they accepted. The carrier cited the proactive approach to our corrective action as the reason for accepting the check as payment in full. The carrier accepted $13,500 rather that the $151,000 originally requested by the PSC.