For

THIRD PARTY PAYORS

Effective December 1, 2004

The facility will provide face-to-face defense services for third party auditors following the facility’s corporate policies including the following policies:

1.1 Any intent to audit or request to copy records an account will require written notification to the Senior Director of Professional Resources after the discharge bill.

1.2 The engagement letter will contain the following information: (1) name of patient; (2) patient account number; (3) dates of service (including pre-op services dates which may be included on the inpatient stay); (4) reason the claim was selected for audit; (5) name of insurance carrier requesting an audit; (6) name of firm and person (if known) performing the audit; (7) total charges; (8) release authorization form (terms of admission are not acceptable)

1.3 Requests for medical records for on site review must be accompanied by a signed and dated release from the patient. The release must specify the dates of service to be audited, and should name the insurance carrier and/or audit firm to which the medical records are being released. Terms of admission will not be accepted as meeting the above criteria. Documentation must be specific to the facility. Audit request must be for an inpatient stay.

1.4 All audits will be performed on-site. No part of the medical record will be made available for removal from the facility under any circumstances. No document copying will be allowed. No technology is allowed used in the presence of the document, including cameras, cell phones, or any other image duplicator.

1.5 A single account may not be audited more than once, any additional requests to audit will be denied. The findings of the first audit will be used as the results for any additionally requested audits.

1.6 Insurance Auditors or agents must comply with Federal, State, Contractual, and Ethical standards regarding confidentiality of medical records.

2.1 Prior to scheduling the audit, 95% of the total billed charges must be paid subject to the patient’s insurance policy.

2.2 Audit requests will not be considered if greater than six months after bill date of insurance.

2.3 The facility will make best faith effort to schedule the audit to take place within one hundred twenty (120) days of receipt of written notice to audit.

2.4 Accounts assigned to collection will not be considered for an audit unless the request came within the first six months after discharge.

2.5 The third party auditor may not request copies of the discharge bill from the hospital. The insurance carrier must provide this information.

2.6 Under no circumstances will off site auditing be allowed. All audits will be conducted on site with the medical auditor, unless allowed on a case-by-case basis by the facility auditor.

2.7 A written request must be made to re-schedule or cancel a scheduled audit. Additionally, a re-schedule fee of one hundred dollars ($100.00) will be charged for re-scheduled audits. An audit may be re-scheduled only once.

2.8 Should the auditor fail to appear the audit would not be re-scheduled. There will also be a cancellation fee of $100.00 that must be collected prior to any further scheduled audits.

2.9 Any audit scheduled or tentatively scheduled via the disposition of a “Letter of Intent” that is subsequently canceled will be considered “closed for further review” unless a new “Letter of Intent” falls into allowable parameters as outlined in item 2.2.

2.10 Auditor identification must be provided on each audit inquiry or visit. This identification will be presented to the medical records department upon arrival and will constitute the beginning of an audit followed by acquisition of an audit fee. The auditor will provide:

  a. The opposing auditor will need to present two forms of identification upon arrival to HIM. These MUST include a state drivers license that is current (not expired) and an ID from the firm that employs them as either an employee or subcontractor.

b. The opposing auditor will provide the facility with a criminal background (upon request) check that is updated every 36 months.

  c. Failure to provide these documents will result in a denial of access and incur a reschedule fee.

2.11Audit Fees

$175.00 contractually to United Healthcare - All audits, any size

 

$200.00 for encounter of <$75,000

$350.00 for encounter of $75,000 - $200,000

$500.00 for encounter of $200,000 - $500,000

$1,000.00 for encounter of $500,000 - $1,000,000.00

$1,500.00 for accounts over $1,000,000.00

Additional $1,000.00 for each successive million dollars if account is multi-millions

$65.00 for encounter DRG Validation Review (per encounter, not per patient record)

$25 cents per page for copying - copies must be done by requestor. The facility will not provide copies.

$200.00 to reschedule an audit

Any further or different requests may be subject to a fee or refusal of access.

The facility reserves the right to refuse access at any time for any or no reason.

3.1 An Audit shall be defined for these purposes as a comparison of the facilities billing vs. the documentation. It shall not include discussions on physician practice and/or DRG coding. It may also include coding, DRG, CPT, and any other outside inquiries.

3.2 An itemization of under and over charges must be completed by both auditors at the conclusion of the audit. This itemization and/or accompanying forms will be considered the final report and will permanently conclude the audit. If only one party typically reports their findings then that party will deliver their findings to the facility within 30 days of the review.

3.3 Both unbilled (undercharges) and unsupported (overcharges) must be included in the final report from the third party auditor. These findings must include description, price, and be summarized by department.

3.4 The audits must have exit conferences, and be summarized and signed-off by authorized representatives of both parties.

3.5 No consideration will be given during the audit to the carriers non-covered items. The hospital will not consider these as unsupported or overcharged items for purposes of the audit.

3.6 Room and Board charges are initiated upon admission orders and are not based on patient location. The hospital will not reimburse room and board charges based on time of arrival to a unit. Staffing and other prepatory measures require hospital expense in preparation for the patient’s arrival.

3.7 If necessary the hospital will submit an additional bill that itemizes previously unbilled charges identified during the audit.

3.8 The hospital reserves the right to terminate an audit for perceived misconduct by a third party auditor. The hospital reserves the right to refuse an auditor access based on past misconduct.

3.9 No direct contact with departments will be allowed by the third party auditor. All aspects of contact will be with the hospital auditor.

3.10 If the insurance carrier receives a discounted or contracted rate, all refunds will be calculated using the same discount formula.

3.11 Any audit containing disputed or disagree items will not be finalized until this dispute has been arbitrated by the auditing company and hospital. All disputed items will be rectified with both parties before final results are submitted. If no agreement can be reached in 90 days the items will be left on the billing as originally billed, and the audit will be considered complete.

3.12 Audit fee payment process and audit workflow will be through Health Information Management and the hospital Cashier via the Business Office. Health Information Management will maintain an audit calendar supplied by Audit Department via Quality Assurance and Compliance. This calendar shall have the current and following months scheduled audits and shall be delivered by the tenth of each month to HIM from Internal Auditor. Calendar shall contain patient name, date of audit exit, account #, and audit fee amount due. External Auditor shall proceed to cashier and pay for all audits to be reviewed that date as scheduled. Auditor will take the receipt from cashier to Health Information Management who will compare to the audit calendar and then allow auditor to review record. External auditor should only view records for which auditor has been given a receipt. Records with a zero due or excluded payment will be allowed if so indicated on the calendar. External auditor shall provide Internal auditor with a copy of the receipt from the cashier. Checks from payer or third party audit firm shall have no PHI posted to the actual check in accordance with HIPAA.

4.1 Please contact the facility at [telephone number], [contact person], or [email address]. Written requests for audit should be sent to:

Facility Name

Facility Address

Attn: Facility Contact Person

Third Party Auditor Agreement

The third party auditor and their representative agency hereby agree to abide by the terms and conditions contained above.

_________________________________

Third Party Auditor

_________________________________ ________________

Print Name                                           Date

 

                   

DEFENSE AUDIT POLICY

For

THIRD PARTY PAYORS

KEY PAGE

Effective December 1, 2004

 

1.2 The engagement letter will contain the following information: (1) name of patient; (2) patient account number; (3) dates of service (including pre-op services dates which may be included on the inpatient stay); (4) reason the claim was selected for audit; (5) name of insurance carrier requesting an audit; (6) name of firm and person (if known) performing the audit; (7) total charges; (8) release authorization form (terms of admission are not acceptable)

 

2.1 Prior to scheduling the audit, 95% of the total billed charges must be paid subject to the patient’s insurance policy.

2.2 Audit requests will not be considered if greater than six months after bill date of insurance.

2.7 A written request must be made to re-schedule or cancel a scheduled audit. Additionally, a re-schedule fee of one hundred dollars ($100.00) will be charged for re-scheduled audits. An audit may be re-scheduled only once.

2.11 Audit Fees

$175.00 contractually to United Healthcare - All audits, any size

 

$200.00 for encounter of <$75,000

$350.00 for encounter of $75,000 - $200,000

$500.00 for encounter of $200,000 - $500,000

$1,000.00 for encounter of $500,000 - $1,000,000.00

$1,500.00 for accounts over $1,000,000.00

Additional $1,000.00 for each successive million dollars if account is multi-millions

$65.00 for encounter DRG Validation Review (per encounter, not per patient record)

$25 cents per page for copying - copies must be done by requestor. The facility will not provide copies.

$200.00 to reschedule an audit

Any further or different requests may be subject to a fee or refusal of access.

The facility reserves the right to refuse access at any time for any or no reason.

3.1 An Audit shall be defined for these purposes as a comparison of the facilities billing vs. the documentation. It shall not include discussions on physician practice and/or DRG coding. It may also include coding, DRG, CPT, and any other outside inquiries.

3.3 Both unbilled (undercharges) and unsupported (overcharges) must be included in the final report from the third party auditor. These findings must include description, price, and be summarized by department.

3.5 No consideration will be given during the audit to the carriers non-covered items. The hospital will not consider these as unsupported or overcharged items for purposes of the audit.

3.6 Room and Board charges are initiated upon admission orders and are not based on patient location. The hospital will not reimburse room and board charges based on time of arrival to a unit. Staffing and other prepatory measures require hospital expense in preparation for the patient’s arrival.