Highmark Audit in Pennsylvania

The Martin Law Firm is a health law firm located in Blue Bell, PA. Attorney Jason B. Martin represents health care providers facing Medicare audits and insurance audits including those performed by Blue Cross Blue Shield. Health care providers challenged with a request for medical records as a precursor to audit activities or an overpayment determination should seek the assistance of experienced legal counsel immediately.

 

Highmark BCBS Audit

For health care providers in Pennsylvania, Highmark BCBS is one of the largest health insurance issuers. Blue Cross Blue Shield (BCBS) entities throughout the country, including Highmark, are known for aggressively pursuing the recovery of overpayments through post payment reviews or audits. The information contained herein focuses on the Highmark audit, but BCBS entities all over the country have similar processes and procedures for commencing an audit and seeking recovery of alleged improper payments. Attorney Martin is licensed in Pennsylvania and New Jersey, but he represents health care providers all over the country with the assistance of local counsel, if necessary. Since post payment reviews are a very narrow focus in the legal profession, providers should consult with health law firms with experience in these matters.

 

Highmark BCBS Process in PA

The Highmark audit begins with a request for medical records. Usually, Highmark determines that a provider’s claims or billing patterns are unusual, and Highmark wants more information to confirm whether the provider’s claims are compliant with laws and Highmark policies. Patient complaints and disgruntled employees can also trigger an audit. Before submitting the records, the health care provider should understand his or her legal rights. Perhaps an argument can be made that the provider is not obligated to submit the records. HIPAA may also cause concerns about the release of records. Generally, in-network providers are contractually obligated to comply with a records request, and some states have laws that mandate compliance.

Prior to submitting the medical records, a good health law attorney will review the records with a qualified coding expert. This will enable your lawyer determine whether any problems exist, help you take corrective action, if necessary, and determine whether supporting information should be submitted that may help explain the history of patient care.

The purpose of submitting additional information is that it can help the Highmark or BCBS consultant understand the documentation better, leading to a more favorable outcome. For example, your attorney may help you create summary reports, which are brief written narratives that help summarize the care and further explain the information in the records. Health care providers should not do this on their own, as altering medical records is a serious and punishable offense. Your attorney can properly submit the records with the summary reports to Highmark or another insurer with an explanation for the purpose of the summary reports and an express statement that the summary reports are not patient records, but merely a summary.

Following your submission of the records, Highmark will have the records reviewed by a consultant, and the consultant will make a determination. Some of the more common adverse determinations are post payment denials based on lack of medical necessity, delegation of adjunctive procedures to unlicensed personnel, illegible notes, maintenance care, billing manual therapy to the same region of the spine as an adjustment, improper use of Evaluation and Management codes, and so on. If Highmark has a large enough sample of claim by claim denials, Highmark will use a statistical method of extrapolation to deny similar claims over the entire patient base for a given time period. This can lead to a large request for return of the “improper” payments, known as “overpayments”.

At this time, a skilled attorney can really help challenge the overpayment calculation. An attorney can challenge the merits behind the denials, e.g., that the services were properly documented to support medical necessity. An experienced health law attorney can challenge the statistical methodology used to calculate the extrapolated amount. In many situations, an attorney experienced with ERISA can make strong legal arguments that challenge the sufficiency of the review and audit process and whether BCBS has a legal right to seek repayment of the overpayment.

 

BCBS Audit Attorney | Montgomery County, PA

The Martin Law Firm has handled hundreds of insurance and Medicare audits, including Highmark audits. Clients of The Martin Law Firm include physicians, group practices, chiropractors, SNFs, ASCs and other entities. If you are being audited and would like to discuss how The Martin Law Firm can help, please call us toll free at 1-877-777-9373 or click on the following link to connect with a health care attorney. Click here for more information in our health law blog or to find out more about our health care services.