Provider audits

We audit the billing of our participating physicians, dentists, other health care professionals and facilities. While many of our audits are to determine whether we have been appropriately billed, we also audit to determine:

  • Medical necessity
  • Proper utilization
  • Coverage of services
  • Appropriateness of services
  • Accuracy of claims submitted

All audits comply with the laws, statutes and regulations pertaining to the confidentiality of member records. Information is not disclosed, except to accomplish the audit or report findings/conclusions where appropriate and necessary.

As a responsible health care services contractor, we are obligated to ensure the integrity of claims submittal and its reimbursement system. Therefore, it is our policy to exercise our contractual ability to audit documentation in support of claims submitted on behalf of our members.

Additional audit provision information is available in your Health Plan agreement.

What you should know about pre- and post-payment audits

Our Clinical Audit Team is dedicated to ensuring that claims have been paid correctly by performing pre- and post-payment audits. Overpaying or underpaying for services rendered is a disservice to both our providers and our members.

Please note:

  • Any claim may be subject to audit to determine appropriateness of service and payment.
  • If we request records for an audit, the records must be submitted within the time frame in the records request letter. If the requested records are not provided within the specific time span, the processing of the claim could be delayed or the entire claim may be recovered if it was previously paid.

Audit tips

  • Follow instructions in the request letter
  • Submit the requested information electronically
  • Submit all information prior to the due date indicated

High-Dollar Audit

We are responsible for performing reviews of all claims that meet certain criteria as stipulated by the provider/facility contract. The high-dollar audit is designed to verify the accuracy of the line item charges submitted for payment in a provider's itemized bill as indicated by the medical record.

This review is not based on the medical necessity of the services provided or the accuracy of the coding. It may be performed either pre-payment or post- payment.

Records are requested for all claims reviewed under the high-dollar audit process. We require the complete medical record for these audits. If the requested records are not provided within the time span identified in the letter, the claim will be closed until the requested information is received.

Once we have completed our audit, the provider will be notified of our findings in writing and for pre-payment reviews, the claim will be processed according to the audit results. For post-payment reviews, overpayments and underpayments will be delineated in an Audit Detail worksheet sent with our Finding Letter. If the provider does not agree with the determination, appeal rights are also delineated within the Finding Letter.

Skilled nursing facility level of care audit

Selected Skilled nursing facility (SNF) claims will be required to participate in a level-of-care audit for Medicare Advantage to:

  • Validate accuracy of Resource Utilization Group (RUG) coding
  • Assess compliance with Minimum Data Set (MDS) assessment requirements

When the claims of a skilled nursing facility are selected for audit, the provider will be notified by mail. We will:

  • Request the complete medical record, including the MDS to support the RUG for the dates of service billed.
  • Include in the request instructions and options on how and where to submit the requested records.
  • Upon the conclusion of the audit, send a letter indicating the audit outcome that includes any overpayments or underpayments we found in our audit and any next steps needed by either party.

Please note:

  • It is the fundamental responsibility of every provider to bill and code accurately. A span of care is comprised of thetime from admission to discharge.
  • The Resident Assessment Instrument (RAI) manual governs submission of MDS assessments for SNF patients.
  • This is a review of the services provided as defined in Chapter 8 of the Medicare Benefit Policy Manual. There is no member liability.

High-dollar inpatient BlueCard hospital bill audit

We also conduct audits on high-dollar inpatient BlueCard host claims. Our vendor, Trover Solutions, performs BlueCard audits. If you have claims selected for this audit, you will receive a letter co-branded with Regence and Trover Solutions logos.

Regence performs all other non-BlueCard high-dollar audits. Please be sure to follow the instructions on the records request letters you receive to ensure compliance to the record return deadlines and the location where records should be sent.

Clinical Audit Team audit process time frame requirements

As part of our ongoing payment integrity audit process, we inform our providers of any upcoming audit activities requiring medical records that may impact them. Here are our expectations of submission of medical records for audits. There are no exceptions to the following policies, unless otherwise required by law:

  • Providers must submit records according to the time frame indicated in the medical record request.
  • We will initiate a technical denial recoupment for the claim or the item(s) within the claim that is (are) under review for providers who have not submitted all of the requested records by the deadline.
  • Records received from providers after a technical denial recoupment has been initiated by us will be reviewed in the order received.
  • Providers may submit records post-closure or technical denial recoupment within 18 months after payment of the claim or notice that the claim was closed. (Note: Hospitals have different time frames. Refer to contract terms for specific time frame.)
  • Records received after the timeframes indicated above will not be reviewed. The postmark date, the fax date or email date on the provider's submission will be deemed the date of receipt.
  • If we receive records after the dates indicated above, we will notify the provider that the records were late and that no review or adjustment will be made.

External Audit and Investigations

Audits are also done in the case of abusive billing practices or to determine the possibility of fraud. Trained auditors review all areas of medical services.

If a special investigation of your payments is warranted, it will be conducted by our External Audit and Investigations staff. Copies of relevant records may be requested by mail or an audit may be conducted in your office at a mutually agreed date and time within the time frame specified in your agreement with us. In the event of an audit in your office, please allow sufficient space to review records and copy those records relevant to the scope of the audit.

The records review will occur at our offices. We will protect the confidential nature of the member records. We will destroy all copies of documentation acquired from an external audit review in a manner that will protect the integrity of confidential information and abide by all laws, statutes and regulatory requirements concerning the protection of confidential medical health care information once the audit file is closed and the need to retain any such information no longer exists.

Refundable situations

While findings will be different for each audit depending on audit area, contract language and our policy, the following are considered refundable to us in the absence of specific language in the provider or facility agreement to the contrary. There are no exceptions to this, unless otherwise required by law:

  • Items not listed within the operative report or documented in the medical record
  • Items for which there is no physician's order (even if documented in the medical record)
  • Notification from the provider that he or she has no records for date of service; all charges will be removed
  • Itemized billings that are not consistent with the claim you electronically submitted for payment