Both government and private payers continue to aggressively monitor providers to prevent and recover overpayments. This is evidenced by the fact that the number of audits conducted in recent years has increased dramatically. A negative audit finding can result in the need to repay five- and seven-figure amounts.
Explore this issue:March 2016
Types of Audits
Private Payer Audits
Private payer audits take two forms: 1) informal reviews and 2) formal audits. These audits can be the result of actual allegations or evidence of non-compliance, or they can be random, in which general compliance is assessed. The procedure for such audits is typically determined by contract or the payer’s provider handbook and in accordance with applicable state law. Prepayment reviews may be conducted, in which the sufficiency of a claim—and its supporting documentation—is determined before payment is made to the provider. Post-payment reviews can also be performed, during which claims are analyzed after the provider has been paid to determine if an overpayment was made.