Provided by:  Jennifer Kirschenbaum, Esq.

April 28, 2022



Hi Jennifer,

I received a letter that I am on prepayment review.  My claims are being held up and I need to send records in to be paid.  How do I get removed?

Dr. K


There seems to be an uptick lately in audit activity, including prepayment review.  As a refresher, you land on prepayment review when a payor determines your claims represent an outlier from billing patterns, and the payor estimates your documentation will not match codes submitted.  Prepay review holds claims in abeyance until records are provided to substantiate the codes submitted.  

Payors take the position the prepayment review will remain until such time as the documentation and claims meet their standards, which oftentimes requires high volume of additional claims provided for review and can take months. 

So, how can you speed up the review process and remove the impediment to claims processing?  Once flagged for prepayment, most carriers will appoint a point person to your matter - sometimes a special investigator our of their fraud unit (doesn't mean you are guilty of anything necessarily, but certainly a move to intimidate).  Here, you're in a tough spot because you can communicate but what you communicate may be used against you.  You can fight on several fronts - 1. coding support (use of carrier policies and Medicare policies to dispute coding reviews), 2. documentation support from your own records (do not change records after visits - that is fraud!), and 3. the law - legal recourse for improper conduct by the carrier.   You may (likely) will benefit from the involvement of your own coding expert to provide support and assessment.  You should be working with attorney to manage the process for you and shield you from direct communication with the carrier.  

To discuss your specific circumstances, give me a call.  Unfortunately (due to client need), we have to work on pre and post pay audit as normal course.