THIRD PARTY AUDIT POLICY
I. PURPOSE
This Policy Outlines the billing audit guidelines for third party payor audits to ensure the accuracy of charges included in or omitted from a bill.
II. SCOPE
a. Audit shall be limited to verifying charges are for services rendered and supplies provided are accurate.
b. The audit will include overcharges and undercharges, which include unbilled charges identified during the auditing process.
c. This policy pertains strictly to billing audits. Therefore, the level or scope of care, medical necessity, or the pricing structure of items or services will not be addressed.
d. Cost data will not be included.
e. Audits will not be scheduled that will not change the reimbursement status.
f. Desk audits are not permitted. All audits will be conducted onsite with internal auditor present to encourage and promote mutual understanding of the records and answer questions.
g. Copying, Scanning of the medical record or removing any portion of the documentation provided during the audit from the designated audit area is not allowed to ensure confidentiality of records.
h. Audits found by hospital to contain error rates of greater than 10% will render entire audit null and void and payor will not be allowed to continue to audit.
i. Payors submitting audits containing errors due to internal system issues, posting delays or other causes will be prohibited from auditing hospital for one year.
j. Audit will be determined based on member benefit schedules and contract terms signed at time of services rendered not at time of audit.
k. Accounts that have been previously audited or not paid in accordance to Florida statute 627.6131and 641.3155 are not eligible for audit.
l. Auditors that violate Florida statues 627.6131and 641.3155 while conducting audits will be prohibited from performing future charge audits.
m. Payor must notify hospital when intending to use a third party audit firm.
n. Any entity that doesn’t have an approved BAA with hospital will not be permitted to audit.
o. Payors found to offer their auditors remuneration, incentives, benefits, contingency fees, etc. that could call their audit finding into question will not be allowed to audit.
p. 95% of insurance liability must be satisfied to consider account eligible for audit.
q. Claims with a total of less than $50,000 in billed charges will not be considered for audit
r. Audits are limited to 10 per day, 3 days per week (Tue-Thurs) not to exceed 1M in total billed charges per month. Audits are limited to 2.5M for total billed revenue per 3-month period.
s. External auditor cannot be a present or former employee due to conflict of interest.
III. DOCUMENTATION
a. The medical record was not designed to be a billing document but instead document clinical data on diagnosis treatment and outcome. Other sources of documentation to support services were provided are: Ancillary department charge records, treatment logs, individual service/order tickets, hospital protocols linking supply items to a specific services.
b.
IV. NOTIFICATION OF AUDIT
a. All notification of intent to audit and the basis of audit must be received in writing with in 12 months from receipt of final bill.
b. Once receipt of notification has been acknowledged, provider shall have 30 days to respond to audit request.
c. Audit requested will be scheduled in the order in which they are received and no earlier than 30 days following request to allow provider time to prepare, coordinate and research account.
d. Notifications must include:
Basis of Audit
Name of patient and DOB
Date of admission and discharge
Provider account number and insurance coverage number
Who will be conducting the audit (payer responsible for patient account or third party audit company including auditor name) and
Copy of consent/notification sent to patient
e. Notification of intents to audit received from multiple audit firms for the same account will not be honored without payor specifying which firm they have designated.
V. SCHEDULING OF AUDIT
- Patient consent/authorization dated within 90 days of scheduling will be required.
- Scheduling request must be received within 15 months of final bill date to be valid.
VI. AUDIT PROCESS FOR EXTERNAL AUDITORS
a. All signed Business Associate Agreements must be provided at time of audit.
b. Auditor must sign the Policy and Procedure prior to the commencement of audit.
c. All external auditors shall have the appropriate credentials and necessary experience, as defined by the National Healthcare Billing Audit Guidelines, to conduct audits. If an external auditor is deemed to not comply with the guidelines, the audit will be terminated and a request for a new auditor assignment will be made. Hospital may request resume.
d. Exit interviews will be scheduled on all audits performed to review and discuss audit findings.
e. Auditor will be expected to document and submit detailed audit finding on facility-generated worksheet prior to exit interview
f. Provider shall have 45 days to dispute and sign off on audit findings after interview is completed.
g. Once audit is agreed by bother parties and signed off, audit is final. Account will not be eligible for re-audit.
h. Hospital shall have the rights to appeal disputed findings.
VII. CANCELLATION OF AUDIT
a. If circumstances permit a 24-hour notice should be given if either party needs to cancel unrepentantly.
b. Scheduled audits should be cancelled or rescheduled at least 10 business days in advance of scheduled appointment.
c. Failure to notify facility of audit cancellation or cancelled audits with less than 10 days notice will be subject to full audit fee.
d. Request for rescheduling with less than 10 business days of scheduled appointment will be subject to a cancelation fee of 100.00.
e. Inability to pay audit fees at time of audit will result in audit being rescheduled and subject to a cancelation fee of 100.00.
f. Only two scheduling requests will be permitted per account for any reason.
VIII. FEES AND PAYMENTS
a. An Audit fee of 300.00 will be due at time of audit.
b. Cancellation and Audit fees shall be paid prior to commencement of the audit.
c. Future Scheduling requests will not be honored if there are outstanding audit or cancellation fees due.
d. Payment is due within 30 days of Agreed Audits. 10% interest will be assessed to balance owed for delayed payor payments exceeding 30 days.
I ______the external auditor for
______Audit firm, representing
______Insurance have read and understand the
Administrative Policy for Insurance Charge Audits at Parrish Medical Center
And agree to comply with the Policy terms.
Signatures:
______External Auditor Date
_______
Hospital Auditor Date
* Hospital Auditor is not authorized to sign any payor audit that the charges are disputed or do not match facility summary.