What do you do when the auditor just will not respond?

Cavalier40

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I work at a Substance Abuse Rehab and Cigna has been doing audits of all of their out of network providers. I have not heard of a single facility that has passed the audit. We recently had our audit completed and predictably failed (even though a retrospective audit from Optum BH came up with 0 problems during the same time span). We now have a no payment flag placed on our facility and we are forced to refer patients that come in with Cigna to other facilities.

I have been trying to contact our auditor since the day we found out the flag was placed on our facility. She sent me one email that was very terse and stated a letter would be sent out later that week......that was 6 weeks ago and we have yet to receive the letter. Since then I have called and or emailed 2 or 3 times per week and I have gotten nothing. I have no idea why we even failed the audit and at this point all we are doing is turning patients away.

Personally I believe ignoring me is purposeful on the auditors part. I also believe that the audit itself is punitive and is meant to drive out of network providers away from accepting Cigna patients rather than to improve care for their patients. Basically, the longer the auditor ignores me, the longer any appeal process will take. I am wondering if I have any legal recourse in this matter. If the auditor will not respond to me, who do I talk to? Almost all of Cignas plans are self funded, so they are under ERISA, which I believe rules out state insurance commissioners. I am completely lost here and any direction will help a great deal.
 
Your best bet is going to be to consult with an attorney. You have limited recourse being an out-of-network provider as there is no contract obligating Cigna to do anything. An attorney will be able to tell you what legal recourse, if any, is available and help you with any additional appeal.
 
I work at a Substance Abuse Rehab and Cigna has been doing audits of all of their out of network providers. I have not heard of a single facility that has passed the audit. We recently had our audit completed and predictably failed (even though a retrospective audit from Optum BH came up with 0 problems during the same time span). We now have a no payment flag placed on our facility and we are forced to refer patients that come in with Cigna to other facilities.

I have been trying to contact our auditor since the day we found out the flag was placed on our facility. She sent me one email that was very terse and stated a letter would be sent out later that week......that was 6 weeks ago and we have yet to receive the letter. Since then I have called and or emailed 2 or 3 times per week and I have gotten nothing. I have no idea why we even failed the audit and at this point all we are doing is turning patients away.

Personally I believe ignoring me is purposeful on the auditors part. I also believe that the audit itself is punitive and is meant to drive out of network providers away from accepting Cigna patients rather than to improve care for their patients. Basically, the longer the auditor ignores me, the longer any appeal process will take. I am wondering if I have any legal recourse in this matter. If the auditor will not respond to me, who do I talk to? Almost all of Cignas plans are self funded, so they are under ERISA, which I believe rules out state insurance commissioners. I am completely lost here and any direction will help a great deal.


Did you ever get a response on this question? How did you find out you had a flag on your NPI or tax id?
 
I am no longer with this treatment center, but I finally did get a response prior to leaving. I think I did it by bombarding her with phone calls, emails and snail mail. I created a point by point rebuttal of her findings and she actually called me. We finally were able to put together a formal appeal of the findings, but since I am not longer there I will not know the result.

We found out we had a flag on the TIN because they would no longer authorize treatment at our facility.
 
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