Audit Decisions Leading to Absurd Outcomes

healthcare businessBy: Karina Gonzalez

Commercial plans continue their audit activity in 2016 demanding many changes and adjustments yet giving little in return. The 2015 audits have not been completed for the majority of substance abuse providers in South Florida, yet the commercial plans have arbitrarily stopped paying new claims even though it takes them at least 6 months to complete a post payment audit.  If and when a provider finally gets an audit result, payors are imposing requirements that just are impossible to meet.

Payors do not appear to be paying attention to the public health crisis of substance abuse addiction and the ever growing need for treatment.   The assumption is being made by the payors that all providers in this space are over utilizing services and engaged in fraudulent practices, despite the reality that  many providers are doing just the contrary.   

Post audit, independent toxicology laboratories are routinely being asked to determine whether a referring physician adequately discussed lab results with patients, adjusted treatment plans and made recommendations as a result of the testing.  In order to process a claim, payors are demanding that the lab submit the medical records of the referring healthcare provider.   How can a lab possibly comply?  The process would look like this: the lab gets an order with specimen for testing, the results are sent back to the ordering physician, and the lab is then required to have the physician return the portion of the chart showing the interaction between the physician and patient relating to the lab results.  Presumably, the payors are asking the labs to involve themselves into the physician patient relationship and make sure the physician has addressed the results with the patient.

Commercial payors have said in no uncertain terms that each time a claim form is sent in for processing and reimbursement by a lab it must contain documentation of the above described interaction.  Presumably, if the interaction does not occur the lab will not be paid for its services.  Even though a lab does not practice medicine it is expected to gather documentation which it has no statutory or professional responsibility to generate or maintain so that the payor can evaluate medical necessity.  Is the payor confusing medical necessity requirements for a lab versus those for a physician versus those for a facility?  It is all muddled together with no clear direction. The only discernable direction is “no payment”.   Patients suffer in the process as the community of substance abuse treatment providers are unable to keep providing services with no clear cut decision on when payment will be forthcoming.

Hopefully, providers will have confidence to challenge to this type of activity and experience some positive adjustments in the near future.

One thought on “Audit Decisions Leading to Absurd Outcomes

  1. Pingback: Managed Care Contracts: Watch Out for Definitions Section Pitfalls | Florida Healthcare Law Firm Blog

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