Confidently Appeal a Special Investigation Unit Refund Request

Confidently Appeal a Special Investigation Unit Refund Request

Communication is essential to a smooth appeals process.

Your practice was the subject of a special investigation unit (SIU) audit, and now the payer is asking for a refund. You have two choices: pay or appeal. If you disagree with the findings, the smart choice is to meet with the payer, appeal the findings, and use the experience as an opportunity to improve the documentation and coding/billing in your office.

Don’t Stick Your Head in the Sand

Payers are responsible for making sure provider payments are supported by legitimate records. If a payer identifies a discrepancy in a claim you submitted during an audit, you will receive a letter outlining the issue(s) and requesting a return of the alleged overpayment. The letter will contain instructions for how to submit a refund, as well as how to appeal the findings.
Refund requests are serious, and should not be ignored. If you do not respond, the payer will assume you agree with the audit findings. The payer can recoup its funds out of future payments due to your practice; require prospective audits prior to future payment; and/or report your practice to a federal regulatory agency.

Take the Offensive

Submit the appeal to the payer/auditor with supporting documentation, a corrected claim (if indicated), and a cover letter outlining the reason for the appeal. Someone other than the person who conducted the initial review will review the appeal.

Providers Can Learn from an Audit

Payers are encouraged to educate providers on audit findings. They may do this through refund letters, handouts at provider meetings, meetings with network/provider representatives, or with the designated educator for coding and documentation/SIU.
Education and discussion with the payer is highly recommended in cases where the documentation is suspect for cloning. Providers can request a face-to-face meeting with the auditor to discuss the findings. During this meeting, the payer may provide supporting documentation regarding the audit findings. They should also allow time for questions by the provider and staff.
Note: This is not a time to bring up unrelated grievances or issues. A separate meeting should be set up for other issues.
If the audit finding identifies an opportunity to improve documentation or billing, the provider should use that information. Making the correction and improving documentation will not only improve the provider’s bottom line, but reduce the chance another payer will find the same issue, see a pattern, and suspect fraud.

Appeal a Finding of Insufficient Documentation

“Insufficient documentation” is a common audit finding because there are so many things to forget. On the top of the list are: not documenting clearly medical decision-making in the note; not including test results; copying previous records into the present visit; and sending unauthenticated medical records.
Copying forward previous records is a serious problem. The copy forward function in electronic health records has made it easy to “cut and paste” the review of systems, medication lists, and problem lists. But what started out as a time saver has led to over-documentation and false entries in medical records. Payer auditors look at medical records with this in mind, and request refunds based on the copying forward or “cloning” of records that don’t match the reason for the visit.
Insufficient documentation cases are difficult to appeal because most payers do not accept addendums created after the request for records is generated. It’s wise to discuss the issue with the payer at the time of appeal.
For more information on SIU audits, read the article “Receive a Records Request from the SIU? Don’t Panic,” ( on pages 46-47 in the June issue of Healthcare Business Monthly.

Take Your Medicine

Alternatively, the provider can refund the payer without question or further discussion. Either way, communication is essential to a successful relationship between provider and payer.
No one wants to give back money for services rendered. Providers who take the time to document appropriately, and who encourage their billing staff to submit timely and accurate claims, can reduce the chance of having to pay back money to a payer.

Patient Protection and Affordable Care Act; Health-Related Portion of the Health Care and Education Reconciliation Act of 2010. Section 6042/1128J (1) (2) (1) (d) Beneficiary in Health Care Fraud Scheme, Reporting and Returning of Overpayments
Medicare Fee-For-Service 2016 Improper Payments Report, Executive Summary
Medicare B Update, Third quarter 2006 (Vol. 4, No. 3)
Office of Inspector General, December 2012, “Coding Trends of Medicare Evaluation and Management Services”

Evelyn Kim, MBA, CPC, CPMA, CRC, AAPC Fellow, works as the manager of SIU for Community First Health Plans. She has served as past president and vice president for the San Antonio, Texas, local chapter, and is pursuing fraud examiner credentials.

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