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As a treatment center, you’re probably out of network with some payers and don’t know how much you’ll be reimbursed if you treat a client with one of these insurance policies.    

Not all insurance policies are created equal. At first glance, a policy might look great, but we’ve seen two identical insurance policies pay differently for the same services, and these numbers can vary substantially.

Treatment Center Insurance Audit / Zealie

How to Prepare for a Treatment Center Insurance Audit

June 24, 2021

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If you’re a successful facility operating in the addiction recovery sector, you can expect a treatment center insurance audit by one or more payers at one point or another. We’ve seen more and more payers conducting audits in the past few years. In our latest blog, we discuss specific ways audits can start, what to watch out for with each payer, and preventive measures to take ahead of time to avoid audits or get out of them quickly. It’s different with every payer, and we’ve picked three of the biggest insurance companies to showcase how it all works.

Anthem Blue Cross Blue Shield Audits

Most Anthem Blue Cross Blue Shield audits start with a post-payment review. This is when they review claims that insurance has already paid for. Typically, you get a request for medical records. If several deficiencies are found in your records during a post-payment review, you are likely going to be put in prepayment review. Many facilities get concerned the payer will request money back after completing a post-payment review, but in our experience, that is far less likely than being placed in prepayment review. 

Being in prepayment review means you will have to send in medical records with every single claim you submit until you get out of prepayment review. This can significantly slow down payments because the payer will have to review your medical records before issuing payment. It can also lead to a significant number of denied claims if the payer determines your records don’t meet their requirements for payment.

Prepayment Review and the Treatment Center Insurance Audit. Here's What to Expect:

You typically get assigned to an SIU (Special Investigations Unit) agent on the payer side. They are the conduit between you and the auditor. Normally, you can’t directly correspond with the auditor, which makes things more complex. However, if you can, try to schedule a meeting with both the SIU agent and the auditor.

You should consistently follow up with them on every point. Don’t be afraid to call them out on the mistakes that they made in their denials. A lot of times they can’t find the information or they’re not looking in the right place for it, so show them where to find the information they need in the documentation.  

Be the squeaky wheel and stay on top of the back-and-forth correspondence. If there are discrepancies, correct them and provide the documentation again. You should do all that you can to get out of a prepayment review because they can hurt your bottom line. The best thing you can do to avoid an audit is to make sure that all of your clinical documentation meets the payer’s criteria before sending it to them. In essence, you should audit yourself before they do. Compliant clinical documentation is your best weapon.

Anthem Blue Cross Blue Shield typically has an 80% medical records passage rate criteria for their other medical billing verticals. Unfortunately, their behavioral health criteria do not specify a passage rate. Once you reached their passage rate, you would automatically be released from prepayment review. That is why it is so important to be in constant communication with your SIU agent. You should ask your agent frequently when you will be released from prepayment review.

Optum (UnitedHealthcare) Audits

Optum has a very similar post-payment review process as Anthem Blue Cross Blue Shield. However, Optum has a more organized and structured prepayment review process. They use the 80% threshold during the prepayment review process to determine when you will be released from the review. 

Throughout the process, you can request Optum to review your passage rate to see if it meets or exceeds the 80% threshold. If the passage rate meets or exceeds 80%, you will be released from prepayment review. If you don’t meet the 80% threshold, you can request an “education” from their clinical team. During their education process, you will meet with their team and they will go through the reasons some of your records failed to meet their requirements. After this meeting, you will get a sense of what needs to be done to make sure your clinical documentation meets their standards, and you should easily be able to meet them from that point on. 

With Optum, it’s about understanding and meeting their clinical requirements, but it is also about understanding how to navigate their processes and procedures to make sure you get through the prepayment review quickly.

Optum also does something unique that no other payer does. It’s something we refer to as the “friendly phone call audit.” 

It typically starts with someone from Optum calling your facility and saying they would like to schedule a call with some people from your clinical staff to “catch up” or “check-in” on how things are going at your facility. They typically make it sound like the meeting will be very informal, but they also let you know that if you don’t have the meeting, they may temporarily suspend authorizations for care at your facility. Of course, the threat of potentially not getting care authorized leads most facilities to have the clinical call. 

The call is usually very casual and friendly but they ask a lot of detailed clinical questions that mostly revolve around ASAM (American Society of Addiction Medicine) criteria. Often, after the “friendly phone call audit,” you will receive a letter in the mail. The letter will state that Optum believes you are not meeting the ASAM criteria and they are “temporarily suspending authorizations” of care until their concerns are addressed. Those concerns will be outlined in the letter. This “audit” is typically very easy to get out of and should only take you a few weeks. You need to communicate with them extensively about their concerns and make the appropriate changes to address them. If you do this, you should be fine. It is very important to stay on top of this. 

One of our new clients has been in an audit with Optum for over a year. When we called Optum to see what was going on, we found out they were just in a “friendly phone call audit.” We got it handled in two weeks.  

Cigna Audits

Much like Anthem Blue Cross Blue Shield and Optum, Cigna’s process starts with a post-payment review. However, the difference with Cigna is that you might not hear from them for a long time, sometimes as much as a year and a half. A lot of facilities think everything is fine, and no news is good news. That is not the case here.

They usually send your records to a third party to find deficiencies. If they find even just small deficiencies in all the records you sent, they will often assume that those deficiencies exist in all your records. This will lead them to request significant funds back from you. Sometimes it can be every dollar they have ever paid you! 

At this point, it’s time to call your attorney. They usually want to come for a site visit to point out your deficiencies and you want your attorney to be present on this visit.

There is no need to panic. These situations mostly settle for a fraction of the refunds requested, paid over a long period. If you don’t settle this situation with Cigna, you cannot take Cigna policies anymore, so we recommend taking care of it quickly.

How to Avoid a Treatment Center Insurance Audit

If you ever find yourself in a post-payment review, you need to make sure your records are adhering to the payer’s criteria for those levels of care. Most payers follow ASAM criteria so make sure you are too. The best way to avoid a prepayment review is to have great compliant clinical records during your post-payment review. If you find yourself in prepayment review, it is very important to make sure that you review all of your documentation to make sure that they meet the payer’s requirements. If your documentation doesn’t meet the requirements, then you need to make sure your facility makes the adjustments to your program to meet the payer’s criteria. 

At Zealie, we review all of our clients’ records to make sure that their clinical documentation complies with the payer before we send them out. A treatment center insurance audit can be frustrating and time-consuming. So, if you are currently in an audit, please reach out to us so we can help you get out of it quickly.