Insurance audits can raise the pulse of anyone working in the medical field, even when they aren't doing anything illegal.

 

Fear of an insurance company finding an un-dotted "i" or an un-crossed "t" can make your hands shake—the feeling you get when you're being pulled over by a cop. You know you weren't speeding, but you might get a ticket for something else.

 

When a medical biller is reviewing an explanation of benefits, she must be certain the amount being reimbursed is not an overpayment. If a claim is overpaid, it shouldn't be ignored and considered a bonus from the insurance company for a job well done. This overpayment should be handled immediately and returned to the insurance company. Rest assured, spending money that's not rightfully yours will come back to bite you.

 

Because insurance companies conduct random audits, your name might be plucked from a lotto-type bin, except that you're not winning a prize. In the event your name is picked, your medical biller should do an internal audit to make sure the audit done by the insurance company is, in fact, correct. This simple but time-consuming task may save you thousands of dollars. For example, a few years ago, we heard of a scenario that could have cost the physician more money if the medical biller had not conducted a separate audit. An insurance company had just changed some procedure codes, of which the former medical biller was unaware. The audit done by the insurance company demonstrated this error, and claimed that the physician owed thousands of dollars. However, only the codes were incorrect—not the billed amount. So the insurance company didn't actually overpay the submitted claims. The mistake didn't affect the actual finances, because the charged amounts were right. Thanks to the new medical biller's investigation, this was brought to the attention of the department performing the audit. As a result, payment was not required, and the physician saved money.

 

It's the responsibility of the medical biller to bring an overpayment from any insurance company to the physician's attention. Because an employee doesn't have control over their employer's work ethic or integrity, the medical biller will not be found at fault when an error is brought to the table—and ignored. We advise medical billers in this situation to document the overpayment that was made, and also when their employer was informed. They should retain a copy of this documentation for their personal records, so in the event the insurance company performs an audit and discovers overpayments, they have evidence demonstrating the medical biller maintained her integrity. Whether the physician chose to ignore the overpayment is no fault of the medical biller.

 

We advise physicians to always pay back what is not rightfully theirs. Otherwise, the rules of Murphy's Law practically guarantee that one day they'll get caught and end up writing a check that may drain their bank account. This scenario might be attributed to overpayments accumulated over long periods of time, and the insurance company not giving the physician much time to repay it. The insurance company will blame the physician for not addressing the mistake. It may not be fair, yet it does happen.

 

Bottom Line: It's better to call the insurance company on mistakes and save yourself from getting caught in a pricey game.

 

 

Minerva DeJesus and Audi Reyes founded Simple Solutions Billing in Maitland.