October 25, 2018





I received a record request from a carrier - 25 patients for a range of dates.  Does that mean I will also receive at some point a demand for money?  What should I expect?  Why is this happening?

Dr. L


Not necessarily.  You may be under routine audit and if your documentation passes muster, you may receive no demand, or you may receive only an "educational letter" with minor clean up items, depending on the carrier.  If your documentation does not pass muster or you elect not to remit records, there is a chance (strong) you may receive a recoupment request from the carrier for repayment.  As to why you have received the request - could be any reason or a specific one.  Oftentimes targets are chosen for being an outlier of standard billing norms.  Could be use of modifier related, duplicative billing, using 1 person's provider ID for multiple practitioners, to name a few common examples.  Or, could be a routine quality assurance audit, really can depend based on the carrier's department the demand originated from.  It is often somewhat transparent what the carrier is looking for from the demand itself.  

One of the first things we do as counsel on these types of matters is to call the carrier direct to get a further sense of the scope of the audit and intention - and also to limit the volume of records demanding, if cumbersome to produce.  



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