Insurance Auditing


07 Jun Insurance Auditing

The behavioral health treatment industry has seen a rise in health insurance audits and scrutiny of medical necessity of patient services and the integrity of providers and their organizations. Likewise the industry has realized a rise in fraudulent insurance claims and clinical documentation indicating services that are either inflated in scope or not performed entirely. Given the increase in healthcare costs since the implementation of the Affordable Care Act; insurers would like nothing more than to cut costs. Identifying and regulating fraudulent activity a primary way to accomplish this, but how does a provider or organization practicing integrity protect themselves and their patients from these audits and the financial distress they can create?

To begin a provider must evaluate the medical necessity of the services they provide in specific relation to the patient they service. This isn’t a clear cut definition as long term sobriety is not a “one size fits all” possibility. Insurance companies have long used their personal policies and requirements to their advantage in recovering funds or denying payments.

Medical Necessity involves multiple factors including the question of whether services performed are medically necessary to progress an individual’s life to function in society, or if ongoing treatment becomes counterproductive to this goal. In Mental Health and Substance Abuse treatment this is especially imperative as behavioral and mental disorders can be difficult to prove to commercial insurers. For example the Toxicology industry has seen such a rise in fraudulent activity that certain insurance organizations such as United Healthcare require that providers submit very specific documentation to prove medical necessity. This includes state issued CLIA waiver, drug testing notes dated, timed and signed by the specific provider or staff who performed the service and down to the bar code of the actual testing cup for urinalysis. Insurance companies have found drug testing not medically necessary and even at times questionable when the patient doesn’t have positive results from the test. Testing is a standard of the industry as it allows proof that a patient is not abusing their personalized medications, and ongoing documentation proving compliance with treatment protocol.

When it comes to clinical documentation that details groups and individual therapy sessions; many insurance companies have strict requirements to show that therapy sessions actually take place and just how much they relate to a patient’s initial ASAM diagnoses and treatment plan. Documentation should include date and time frames, the number of participants, the group topic and activity, the individual participation, the signature of the provider who was present, and lastly credentials and licensing to go along with it. These requirements and hidden policies are not communicated with providers or billing organizations. At times these have been discovered with no documentation from the insurance to detail these policies. Therefore claims are denied, and medical necessity reviews and audits are frequently occurring.

The most important factor with treatment representation and protection from audits is the filing of claims. Elevated Billing Solutions prides ourselves on the efficiency and accuracy of claim filing. We are determined to make sure the services submitted meet industry requirements. In the unfortunate case of audits our team puts high priority on submitting the most accurate and complete documentation that is provided to us. Every avenue is exhausted in order to ensure that the least financial responsibility is placed on the patient, and the highest revenue is provided to the provider or organization. Recovery of funds for illegitimate audits and denials is also a priority.

High volumes of corrections to claims, and timely filing limits to submit clinical documents has been known to raise flags with insurance companies and increase the risk of audits. Given these strict requirements mandated by health insurance; Elevated Billing Solutions has taken an offensive stance in that we provide training to make sure your organization’s documentation meets industry standards and health insurance requirements. Training is also provided on proper reporting of services performed, efficiency and accuracy of billing, and compliance with timely filing limits.  Our staff is dedicated to relentlessly advocating for individuals who need treatment and taking this battle to the insurance. This is for the sake of patients, and the role providers play in this field.

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