Wiki auditing question

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Jim Pawloski said:
What is your question, as I am an IR auditor.
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Hi Jim, well im working for a Radiology diagnostic center. and just recently we received a letter from BCBS stated we are "doing an exam to much".
not that we are doing it wrong or the documentations don't support the service. just to much.. now my question was how can they tell us this.
example: 76700 Ultrasound Abdomen Complete with duplex/doppler-93975
they said the duplex/doppler 93975 is being billed to much...
 
jesse.chavez@dielp.com said:
Hi Jim, well im working for a Radiology diagnostic center. and just recently we received a letter from BCBS stated we are "doing an exam to much".
not that we are doing it wrong or the documentations don't support the service. just to much.. now my question was how can they tell us this.
example: 76700 Ultrasound Abdomen Complete with duplex/doppler-93975
they said the duplex/doppler 93975 is being billed to much...
Click to expand...
When you get letters like this (and it is not unique to radiology), it basically means they compared your data with data of other providers/practices. Their analysis of this data showed you are using this code more compared to others. Usually at the time of this first letter, no one has even looked at your records. No audit was done. It does not mean you coded incorrectly. Simply that your data did not fall into their bell curve.
In my experience, these types of letters are usually the first step. Some insurance companies want to intimidate you into downcoding/undercoding. As long as you are coding correctly, you should not change anything. I personally hate these scare tactics. Typically the next step would be to conduct some audits of records on your claims. If their audits determine the coding was correct, that should hopefully be the end. If their audits determine incorrect coding, be prepared to dispute their findings and they may start requesting refunds on even already paid claims.

I work in gyn oncology, so our patients tend to be complex. However, most insurances compare our coding data under the "ob/gyn" umbrella. When we get a letter about being an outlier for high coding levels, I send a letter asking to compare our coding data with ONLY other gyn oncs. Usually I get no response at all. If it goes to the next step of requesting records, I would send the records, along with a cover letter explaining there are certified coders in our practice, annual internal audits conducted, and again emphasizing to compare our data only to other gyn oncs.
Years ago, there was 1 carrier who sent a letter but never conducted an audit. When the first letter didn't scare us, they then sent a letter that all E/Ms coded above level 3 would be paid at level 3 and we would have to appeal with records for any higher. That was another scare tactic, again with no audit being conducted. It was almost a year of headaches, but I fought for every penny. Once they determined the % of audits resulting in the higher level we originally billed, they stopped this practice.
 
Thanks for your information Christine. The third party payers don't want to pay for services, just keep our money.

Jim Pawloski, CIRCC
 
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