Legal Brief: Auditing Out-of-Network Providers

With this weekly column, Elite Healthcare provides readers with insight related to the legal implications of healthcare – offering practical guidance on scenarios that should be avoidable and providing suggested courses of action when appropriate. The examples provided here are those that all providers should be aware of, but many aren’t or are negligent despite their awareness. Don’t let your practice be compromised.

Auditing Out-of-Network Providers

Astonishingly, many physicians believe that if they are an out-of-network provider that they cannot be audited. You can, and you very well may be. Anytime you complete insurance form, electronic or otherwise, and sign the bottom of that document, you are certifying that you have used the Current Procedural Terminology and International Classification of Diseases codes correctly. You are, in essence, cashing or depositing a check from the insurance company, and carries with it certain rights as well as obligations. These companies can and do perform post-payment audits. 

The rules and laws differ from state to state, but providers can be audited and asked for money to be returned if it is deemed necessary. Do not be lulled into complacency with an out-of-network status. Providers who refuse to cooperate when asked to provide medical records and/or test results to the insurance company to support documentation may be sued for unjust enrichment and various other counts, depending upon the state. During the discovery phase, insurers will obtain the sought-after documents regardless. While being out-of- network does carry various advantages, it is not devoid of responsibility to the insurance company.

That said, a recent report from the Office of Inspector General, when thoroughly evaluated, highlights that healthcare providers should not accept an audit’s findings at “face value” without further investigation. This goes for Medicare, Medicaid, and private-insurance audits. Consider hiring an experienced law firm to evaluate what is legitimately owed, if anything.


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