Guillermo Beades, Partner, Frier Levitt, and Jim Tudor, Director of Coding & Billing Compliance, HealthCare Compliance Network, discuss considerations related to medical payer audits, from both the provider and payer perspectives. They cover why audits occur; how to avoid an audit; and best practices for handling post-payment audits, pre-payment audits, and pre-payment reviews. Guillermo and Jim recently authored an article for AHLA’s Journal of Health and Life Sciences Law about this issue.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
Guillermo Beades, Partner, Frier Levitt, and Jim Tudor, Director of Coding & Billing Compliance, HealthCare Compliance Network, discuss considerations related to medical payer audits, from both the provider and payer perspectives. They cover why audits occur; how to avoid an audit; and best practices for handling post-payment audits, pre-payment audits, and pre-payment reviews. Guillermo and Jim recently authored an article for AHLA’s Journal of Health and Life Sciences Law about this issue.
To learn more about AHLA and the educational resources available to the health law community, visit americanhealthlaw.org.
This episode of A H L A Speaking of health law is brought to you by a HLA members and donors like you. For more information, visit american health law.org.
Speaker 2:Hello, my name is Guiller mos. I am a partner at Fryer Levitt, where I serve as co-chair of the Insurance Defense Group. I've represented providers in regulatory, civil, and criminal matters that primarily focus on billing practices. I also represent healthcare providers before state licensing authorities, medical boards, and defense state and federal investigations. I'm joined today by James Tudor of Healthcare Compliance Network, who is my long-time collaborator and co-author of our A H L A journal article, the Dos and Don'ts of Medical Payer Audits out to identify and respond to them. Kim is over 30 years of experience in the coding and billing space, and has worked on both sides of the aisle, which gives them particular insight into areas of risk for practices and how to defend audits. Our podcast today will expand upon our article that was published in ALA's Journal of Health and Life Sciences Law. The article was written with a focus on identifying and responding to payer audits, which is provider-centric. Today, we will revisit some of the issues discussed in the article, but also take the time to play devil's advocate and know where we would focus if Gemini were on the other side, on the payer side. For those of you, uh, who may not be well versed in the area of payer audits, allow me to quickly set the stage what we're about to discuss. First off, when we refer to payers, what we mean is both private insurance companies and public payers, like the CMS and Medicaid strategies implemented by the CMS, are the same as those implemented by UnitedHealthcare Emblem Horizon, Aetna, Cigna, or any of the other private insurance companies. Second, when a provider agrees to participate in network with an insurance company, their provider agreement requires them to comply with all documented requests and audits. Therefore, if an in-network practice receives an audit with very few exceptions, they have no option but to fully comply. Out of network providers are slightly different, but they're also not immune from being audited. When a payer identifies a practice or provider as the target for an audit, there are different ways that they can investigate. There are post-payment audits where insurance companies look to take back money that was previously paid, sometimes with an extrapolation prepayment audits, where insurance companies will not pay until they review records for the services bill and prepayment reviews, where it's a bit of a hybrid audit where records need to be sent prior to payments. But if the services get consistently denied, insurance companies then will extrapolate and claw back money previously paid. These audit tools bring about different types of risk that require legal and coding expertise to navigate properly. With that as a backdrop, uh, let's get to, uh, some questions, Jim. Um, sure. The first question that, that you and I always get is why am I being audited
Speaker 3:Every single time? How
Speaker 2:Does a practice get chosen to be audited? Yeah.
Speaker 3:Why us? You know, we do things the same way the guys cross the street do. We've been, you know, uh, in practice for 20 years. We have no history of being audited. You know, we can't imagine that there are any red flags. But truth be told, uh, if you're being audited, there are some red flags. Um, you know, least commonly, I think you get things like a patient complaint or, you know, a whistleblower. Those are kind of rare situations from the audit perspective. Uh, they certainly do happen. But, uh, the number one reason for the, for an audit to be generated is an a barent, um, billing profile. Um, and that could either be, um, a summary profile of the practice at large, or it could be individual provider or providers, um, who, uh, have abnormal billing. Um, and there's a couple of things that they look at when they're trying to make that determination. The first one, uh, is the volume of codes that are being billed. So every C P T code has a typical time associated, uh, with it. Some of them are, uh, very obvious as evidenced by the code description. This is a level three e and m code that's 20 minutes, et cetera. Um, but all C p t codes have, uh, a typical time based on the pre-service work, the inter, uh, procedural work and the post-work, um, that generally encompasses that particular code. Um, and if one way that they can identify potential outlier is just by simply adding up the typical times associated with your codes and then say, you know, on an average day, you're billing for a 45 hour day, which we don't have on planet Earth. So, you know, we know something has to be wrong. Um, you know, and it's, it's that impossible day scenario, as they call it, is something that we've seen, you know, a lot more reliance on, uh, from the payers over the course of the last few years. Um, and it's also, I think with that being said, worth noting that the, uh, typical times on some of the e and m codes, um, have changed, actually increased starting with the e and m coding changes from two years ago. Uh, so now it's even be more obvious if they're using the current benchmarking, uh, of typical times, it's not gonna be as hard, uh, for them to come up with that impossible day termination. The other thing that they can look at, um, is an abnormal distribution of the code. So in comparison to, uh, other providers in your specialty, in your zip code or or other geographical area, you know, you bill 25% more level five visits than your peers do. Um, and of course, neither that nor the impossible day scenario necessarily, uh, means that anything is, uh, uh, fraudulent or, uh, disingenuous about the billing. It just simply means that for whatever reason, you know, you're an outlier based on, uh, the distribution or volume. The other thing, um, is inappropriate use of, uh, code pairs modifiers. Uh, of course, we have something in coding, uh, called bundling, which is, uh, the, uh, in, uh, inclusion in the C P t, uh, uh, code book of a comprehensive code that encompasses at times several individually reportable codes if they were done on their own. Um, and there are certain rules as to when you can unbundle and on at times, that's actually perfectly appropriate. Uh, but if you have too many modifiers which, uh, are indicative of potential unbundling, uh, the payer is gonna wanna take a look at your notes to make sure that you're following the rules and documenting appropriately. So, those are the three or four top reasons I would say, Guillermo.
Speaker 2:Right. It sounds to me that, you know, a lot of these providers sort of fall into a false sense of security because maybe, you know, Hey, everybody else is doing it, or, you know, I've been doing it for so many years, you know, and now after decades of doing this, I'm, I'm getting audited. Um, what can a practice do proactively to avoid being audited? Even one that maybe has never been audited in 20, 30 years? You know, um, what should they be doing?
Speaker 3:Well, given that the number one reason generating audits is, uh, you know, data analytics, the, the, the first thing that a practice should do would be, uh, to continuously monitor their billing for abnormal volume, abnormal, uh, uh, dissemination of codes so that you're not appear appearing on anybody's radar. Um, I would do that first and foremost. Now, sometimes it is what it is. You know, if a particular practice, um, has, uh, higher than normal prop, uh, propensity to have, you know, complicated patients, or for some reason they spend more time with their patients, you know, and they're billing those codes that are time-based, you know, the payer doesn't know that from looking at your billing. They just know from crunching the numbers that something could quote, unquote, be wrong with it. So you wanna make sure that, you know, you take that bird's eye view, uh, and every now and then, take a look at your codes by distribution and volume just to make sure everything looks okay. Um, and then you can certainly reach out, um, online and find various resources, which, uh, such as c m s themselves, um, M G M A, sometimes the, uh, private payers offer billing, distribution, you know, metrics, or they'll send you a letter. Uh, there's various ways to know, uh, and they're not all that easy, not all that difficult, I should say, to, to, to come across where, you know, you can do a quick check, uh, gut check on your billing. Um, and then beyond that, you know, every practice, you know, it's really incumbent upon everyone nowadays to have some, uh, sort of, um, auditing and monitoring regimen in place in their o office. There's nothing that says, you know, uh, you know, thou shett have, you know, an army of auditors or code editors, you know, doing this work for you. Uh, and in the end, the payers really don't care what you do, what checks and balances you have in place, as long as you're getting it right. So, however you choose to do that, and there's a wide, uh, variation as far as the, uh, type of individuals who could be involved with that op optimally, you want like a certified coder or auditor, someone who knows the business and is, you know, attuned to all the changes in the industry. But it need not be, you know, that the case, it could be, you know, a, a biller. It could be, uh, you know, a clinical staff who has a lot of knowledge, uh, and expertise in that particular area. It could be a physician. You know, it's kind of uncommon in my experiences that the physician gets, you know, really knee deep into that kind of thing. But I do, I can name a few, uh, I won't right now, but I could name a few that are really very well educated. Right.
Speaker 2:If you have a practice, let's say, that's hyper-specialized, there's not too many peers, you know, what, what, what advice would you have for attorneys who represent practices that are hyper-specialized?
Speaker 3:Yeah. You know, and first of all, I would tell them that just because you're an outlier doesn't mean you're doing anything wrong, as I'd mentioned earlier, just cuz you have high volume or maybe more complex patients, and, uh, you appear on someone's radar, you know, that that does not in an in and of itself infer guilt in any way. Um, so, you know, that comfort level needs to be established and they should continue to bill for the services that they're are, are medically necessary that are well documented in the chart. Um, that's definitely my number one suggestion, is if you're gonna be potentially rife for audit activity, um, in the future, then you wanna make sure your notes are as strong as possible, you know, bulletproof to whatever extent, uh, they can make them. Uh, you don't want overkill in the notes because, you know, Guillermo, you and I have seen many times where provider has six pages of office note for a runny nose, you know, that kind of thing. Yeah. You know, there seem to be leaning away from, you know, superfluous documentation in recent memory, uh, that actually, you know, you could be shooting yourself in the foot in that regard. And then staying ab, uh, on top of all the coding changes or payer policy changes, you know, uh, how many times do we hear, you know, I thought Medicare handled it a certain way, but apparently they changed their ruling on it. You know, and this is more common, you know, be staying out of touch is more common than staying in touch with many practices. I actually had a, uh, an onsite audit I did not that long ago. It's kind of rare nowadays. But, um, uh, when I got to the office, I asked the, uh, biller slash coder, uh, what they used for resources, and the first thing she did was pull out a 2000, 2007 C P T manual<laugh>. And I was at a complete loss for words. But that's, you know, more common than you might think, actually, that kind of thing.
Speaker 2:And that's the one thing that, uh, that that unfortunately, um, is I think, misunderstood, uh, by providers that compliance doesn't scale. Compliance is, it's yes or no, you know, you can't be a little bit compliant, just like you can't be a little bit pregnant, uh, you are or you're not. So, right. It, it, it's a burden on, on smaller practices, but, you know, they're all required to bill accordingly and document accordingly. And you, you and I have seen them, uh, unfortunately, uh, take some very small practices to the woodshed over this.
Speaker 3:Um, yeah. But, you know, I think it's important to mention that, you know, although everyone is assumedly reading from the same sheet of music, sometimes those lines on that sheet of music are subject to interpretive variances, which could cause some, um, uh, disagreement in the event of audits. Um, anyone who knows coding to any length knows that there are plenty of gray areas around every corner. Um, there's, you know, and oftentimes we'll get an audit back from a payer, um, and it just seems like the, uh, citations are just kind of coming from nowhere. There is a, you know, a a certain extent of, um, I call it collective illusions in this business where, um, people kind of believe something is so because they just believe it to be so without being able to trace it back to anything definitive. So even though the bullet points are the same everywhere, uh, Guillermo, the application of the bullet points does change. And that's, you know, primarily, you know, what we do in our daily travels is fight, you know, debunk as much of that as we can.
Speaker 2:So I'm gonna ask you then, with our extensive experience, you know, uh, representing providers and ask you to put on the hat of an auditor for a payer. Okay. Let's play devil's advocate for a second. If you were going to investigate a practice, okay. If you were, uh, retained as, you know, an independent expert on behalf of a, a major payer, what codes or types of services would you be focusing on? Is there any areas that you would avoid based on, you know, the defensibility of it or, or what, you know, from working on, on the side that you do now?
Speaker 3:Well, you know, again, the data analytics really pay, uh, uh, really are a very important piece, um, in that investigator's toolbox because they usually, uh, there's something, um, you know, as far as their volume or particularly distribution of codes that, um, kind of blink tilt on their screen. So, you know, that's really the first thing that you're looking at. Um, if you're going to focus on, uh, you know, specific codes or modifiers, you wanna make sure, uh, that you pull a statistically appropriate and reasonable, uh, sample to audit, um, sometimes we find that they don't, uh, you would think that it was, you know, everybody, you know, does a uniform rat stats type of, you know, sample. But, uh, you know, we find that there is a, a great deal of char cherry picking that falls beyond, you know, reasonable and really appears to be disadvantageous to the practice. Uh, but really, you know, if you wanna do it right, and you're working for the quote other side, you know, you wanna take a fair example based on your da data analytics to back you up. Of course, uh, you'd prob wanna do your homework on that particular, uh, practice or physician. And by reviewing the past history, you know, have we audited this provider or this PR practice in the past? You know, what were the results of those audits? You know, is there anything, you know, abnormal that that comes up in upon review of that history? Um, if you, particularly, we find some instances where a, uh, uh, a payer suspects fraud, they will, uh, do patient interviews or staff interviews. Now, the patient interviews, um, I find don't really hold a lot of water. Uh, often that entails asking a patient questions about an office visit that they had three years ago, which, you know, if you, I mean, I can't remember. I had an office visit this morning. I don't remember everything that transpired, let alone asking a 83 year old, you know, what, what did the doctor say this back on March 15th, 2017? You know, it's just not, you know, something, uh, that holds a lot of water, but it's just one more bullet point in their reasons why you owe X amount of money back. Um, staff interviews, you know, provider interviews, uh, to whatever extent you can get folks at the Praxis to, to speak a little bit, uh, usually what they say, uh, can be bent and twisted and contorted, you know, a hundred ways till Sunday. So you wanna make sure that you try to get, you know, someone to put themselves, you know, out there, either, you know, through a phone call or perhaps even better yet by, you know, email or written correspondence. So once you've got all that, you know, all of that going, you know, you can really, you know, get started with some degree of earnest.
Speaker 2:All right, so let's say we get now to this, um, audit stage. As I think I I queued up a little earlier. We got post payments, prepayments, prepayment reviews, um, starting first, you know, with the post-payment audit provider receives, you know, uh, one of these letters, uh, with a post-payment audit demanding a number of records, or even worse, an overpayment demand saying, you know, uh, alleging there was an overpayment done, what's the first thing that they should do? And at the same time, what's the last thing that the one thing that should absolutely avoid doing, gimme one definite do and one definite don't, once you receive
Speaker 3:That, oh, there are, se several definite don't<laugh>, and we have both encountered them in our travels, and they all, um, are the result of a practice really losing their cool, you know, they're freaking out. They got, uh, a letter stating they're gonna be audited, and they're obviously nervous about that before they even get a, uh, any results back. Or they've gotten the nasty letter that everyone dreads, you know, saying, we've done an audit and you owe us, you know, an astronomical amount of money back. You know, losing the cool is the number one thing that you know, such as, uh, I know you and I worked on a case many years ago, Guillermo, where, uh, a provider, um, went through, uh, we're talking about paper charts, went through and added information into the paper charts, literally wrote it in, in some instances his staff wrote it in, it was clearly, you know, jumping out at you different color ink<laugh>, you know, and basically he wasn't writing anything in there that was, uh, erroneous or fal and making any attempt to falsify the information, but he felt that it was necessary to make clear those things which potentially could get misconstrued. So it's, it's, it's definitely good intentions there. But when an auditor sees something like that, the red flags go very high immediately, you know, and the other thing that they shouldn't do, um, and this happens very often, um, is change your billing patterns. So you get a letter saying you're going to be audited, you haven't received any indication whatsoever that you're doing anything wrong, and then all of a sudden you stop billing consults, or you start billing more lower level codes, or, you know, in some other way, you know, there's a seismic shift in your, uh, in your billing, uh, that will absolutely, positively be picked up on, uh, by the payer. And they could, uh, use that, you know, in the negotiations, which transpire after an audit, typically, uh, by saying, well, your client actually started, uh, they stopped billing this code in question be at the time we did the audit. So what are we supposed to, you know, to take from that? Um, they also should not admit things, you know, know in writing or verbally to the investigator that, Hey, we're doing something wrong. We had, uh, a client not long ago that, um, admitted that they were billing, speaking of consultations, uh, they were billing the consultation codes incorrectly. Uh, we became involved and took a look at their charts, and it turns out they were absolutely not billing them incorrectly. So that got thrown back at us by the investigator at a future point as well. You know, the number one thing they should do really, is go into this, uh, you know, especially in the beginning, don't take those findings as gospel, you know, perform a validation, uh, review. If you have in-house staff that's capable of doing it, you know, that's a possibility. But bear in mind, you know, and, and I'm not throwing anyone under the bus by profession or, uh, anything like that, but, you know, sometimes the reason why the practice has become an outlier is due to faulty interpretations or processes within the practice that have led them to become one. Um, so I find that getting an independent expert, um, is a better way to go. Someone with a fresh set of eyes who can take a look at that payer audit sample and say, well, out of, you know, all of their findings, cumulatively we agree with, you know, 30% of them, and the other 70%, you know, some are more solid than others. I think there's, you know, uh, a lot of, uh, weight that should be placed on getting that independent review. Um, and then, you know, systematically, as I say, debunking the findings one by one.
Speaker 2:Yeah, I agree with you. I think staying calm, staying cool, not overreacting, not paying that, that's something that we found, uh, that, that thought to be shocking.
Speaker 3:Uh, yeah. How much do we owe? We want this off our back. Yeah,
Speaker 2:Yeah, yeah. They'll, they'll get an$80,000 repayment demand, um, with no supporting documentation, and they'll pay it.
Speaker 3:Um, and meanwhile, if you're paying an overpayment demand based on the presumption that you're doing something wrong, what have you just admitted to? You
Speaker 2:Know what I mean? You know, usually when, when, when we work on cases, you know, and we get them, you know, at the end of the day, uh, resolved, usually it's by a settlement, no one's perfect. So there's always some sort of error rate. It's a big difference between paying something back with a hundred percent error rate and a 10% error rate. Um, but at least we get, you know, confidential settlement agreements, new admission of guilt, things of that nature. If you're just writing out a check, uh, I mean, like you said, uh, you're just gonna be low hanging fruit, and, and, and you, you may even be, you know, uh, admitting to something. So
Speaker 3:Almost always agree there's something you can fight there. You know, it is very, very rare. I mean, I can count on one hand the number of instances over five years, Guillermo, where the payer was just dead, 110%, right? On absolutely everything they found. Um, and the reason why, uh, often there are, uh, contestable items is because of the nature of coding itself, which has many, many gray areas, many loopholes. It's not as, you know, hard and fast as a lot of providers think it is, which is, okay, well, I've got the bullet points. You know, I got a template in my er, EMR to capture all the bullet points. You know, as long as I check all those boxes, how could it go bad? Right? You know, there's, the devil is really in the details. Everything it seems, uh, all of the nomenclature, you know, you just go through it. And there's something about it that begs further, uh, delineation, further definition, further explanation. How, what do you mean by this word? You know, like Bill Clinton said, define the word is<laugh>. You know, there's, it, it really gets down to that level of detail at times, you know, and these audits. So I think, you know, that's
Speaker 2:Just, I've been surprise working with you many, I more than one audit where a single word, um, added or deleted, changed whether something was p re reimbursable or not, like a single word. Which to me, even as an attorney who, who you deals, you know, with a, you know, massaging language every day, uh, I've never had a, you know, something, turn on a word. Um,
Speaker 3:And, and I always talk about the lia there, how, you know, I, and I used to run audit teams. That would be, we would be all training, uh, together, sitting around a big conference table looking at the same progress note or op report, and the team who was, uh, staffed with people who had 15, 20 years of experience on the average, were all coming up with different answers, or, and if you know, coding, you know what I'm talking about, different pathways to the same answer, and you think, well, how the heck could that even be possible? It's all these things that we just mentioned about, you know, uh, you know, the, the, um, uh, vagueness and, uh, um, incompleteness in many respects to, uh, plugging all those holes in the gray areas, which, you know, they, they make attempts to do that every so often. But it seems that, you know, that perpetually, there are a bunch of'em that, you know, keep that Swiss cheese effect<laugh>, uh, stationary over the course of time,
Speaker 2:Um, moving out to, uh, prepayment audits. Um, yeah, this is again, uh, where you're asked for records, uh, before being paid, uh, to ensure that a documentation, uh, meets a criteria for the code that you're billing. Now that doesn't really sound bad or risky on its face, you know? Um, and we've had some providers we've represented over the years who said, oh, yeah, my prepayment audit, I, I think it's great. I don't, you know, I don't get overpaid. I I don't have to worry about overpayment demands, but you,
Speaker 3:They're gonna see how good our notes are.<laugh>.
Speaker 2:Yeah, exactly. So what's the harm in just not, not giving it the importance that it ha that it, that it needs?
Speaker 3:Well, you know, the other thing about prepayment audits to remember is they usually, you know, they don't pop up, you know, out of thin air. Usually it's, it's pursuant to a process that's already occurred to some extent, where, uh, maybe they've done a post-payment audit, um, and provided education, you know, the t p e audits that Medicare does, where they'll audit you a number of times and you're expected to approve after each round of auditing. They do provide some education. Um, and if you've reached that point where, particularly this prepayment audit, but also a prepayment review, Guillermo too, that, you know, where they can just literally pull the plug on the audit and, you know, slap together, uh, extrapolation going back three years, potentially, you know, at any, any given time. We've certainly seen that, you know, that doesn't, you know, just doesn't come out of nowhere. So you want it, usually if you're there in that position, there's some demonstrated, uh, non-compliance that's, um, chronic, you know, to some degree. So if the provider hasn't made changes, usually they do, unfortunately, you know, that's somewhat rare appearance. Usually provider says, okay, well, I can make these changes, and they follow suit with the necessary modifications to their charts, but sometimes, you know, for whatever reason, they don't, you know, and that can just give rise to that, you know, that mushroom cloud, you know, so they wanna make,
Speaker 2:And, and obviously the cash flow issue, while, while you're on, on prepayment review, uh, there's no, there's no prompt pay. Uh, you know, it's not like you, new New Jersey, for instance, has prompt pay laws where if you submit something, uh, it's supposed to be paid within usually 30 days. I think some insurance companies, if you do it electronically, they'll pay you electronically, like 28 days. Right. Um, but once you're in a prepayment audit, you, you might not get even, even an adjudication on what you sent then for, for weeks.
Speaker 3:Yeah. It's, it's a cumbersome process. Um, we do know, you know, in, in our best practice recommendations, if you're in a situation like that, the best thing to do would be to have a certified coder slash audit or look at your charts before those claims are submitted so that you've got, you know, you wanna make every sure, everything is airtight before that claim goes out the door, which adds, you know, some logistical steps there that take even more time. But in the end, you wanna pass that audit and you're in a prepayment audit, you know, and they're, you're being graded quarterly or the prepayment review, which is, you know, they can stop the presses at any time on you. You wanna make sure that those claims that you're submitting to the payer are, are as accurate and compliant as possible from the get-go.
Speaker 2:And, and you mentioned, uh, the, the prepayment review, which is that hybrid, uh, you know, that that's one where I've seen, um, insurance companies, um, shift towards that model. Yeah. Um, and in speaking with an investigator, um, from an someone, a senior S I U person, uh, they were telling me that, you know, this fairly major, well-known payer, uh, is shifting towards that model a hundred percent because it's cumbersome, it's expensive, it's unnecessary to send somebody out for an onsite, uh, records review and to put someone on a prepayment audit through the prepayment department. Um, you know, there's some logistical issues there as well. But if the S I u, uh, now the prepayment department, the s siu, the Special Investigations unit that handles fraud, waste, and abuse, if they handle a prepayment review, they're essentially, um, controlling, you know, the spigot, they'll tell you how much money they'll, they'll, they'll release based on your error rate, you know, how, how good your documentation is on the prepayment review claims. And once they get a feeling, and, and that's the word that was, that was used to me, once they have a feeling as to your coding, nothing that's nothing an analytical about it. They will come up with the error rate once they've seen enough, which is not a quantifiable amount. Um, but once they've seen enough, they will come up with an error rate and then they will extrapolate and try to seek to recoup going back in New Jersey, 18 months in, um, other states like, uh, New York, it's 24 months. Um, they don't allege fraud, waste, and abuse, which would let'em go back, you know, five years, six years. But they just allege, okay, you're, you're doing this wrong, so you must have been doing this wrong for the last 18 months. By statute, we're allowed to look back 18 months. So now the onus goes onto the providers to show, Hey, that's not an indicative no sample. I actually billed correctly. It almost flips the burden on, well, it does flip the burden on, on the providers. Um, what are some of the challenges you've, you've had with, uh, with prepayment reviews? Cause I'm telling you, if I, if I worked at an insurance company, this is what I'd be using because
Speaker 3:Yeah, I mean, it's
Speaker 2:Load people and then you get money back
Speaker 3:<laugh>. It's disturbing that the trend has become, uh, has moved away from a more prescribed process to a more arbitrary thing where, you know, again, as I'd mentioned, we're gonna, you know, pull the plug on you as soon as we are convinced that you are doing it wrong. And who knows if that's gonna be, um, a hundred claims, a thousand claims, you know, 10,000 claims. You know, we've seen it stopped, uh, you know, as early as, you know, under a hundred, I believe, in the past a couple of times. You know? So I think all of this is, represents very strong rationale, uh, and support to having, uh, some, uh, form of compliance measures in place. And again, there isn't really, you know, this, uh, OIG publishes compliance guidance and part of that guidance, uh, there is a section devoted to, uh, billing compliance. Uh, but they leave a lot of flexibility in there because ultimately they, you know, it's not a one size fits all template that can be used. Uh, there are a lot of different practices, a lot of different specialties, a lot of different variables that, um, exclude the use of one size fits all, you know, methodology there. But everybody has to have something strong in place. And when I say strong, you need the quarterback in that situation to have a full understanding of coding, billing, compliance, and payer policies, and throw into that, you know, the abil strong da, uh, data, analytical skills so that they can, you know, identify potential problems in the past, stay abreast of all the changes in the industry, which are fast and furious at times. Um, deliver education to the providers, deliver it to, uh, IT professionals who can make the necessary changes to the templates and, and notes. You know, it's important to be proactive because, you know, it seems we're just coming to this stage where, you know, they can really do a lot of, they being the payers can do a lot of damage, you know, and you don't want that process to be, uh, it's disturbing to know that it's becoming more whimsical and arbitrary, you know, by the day. But you know, if that's the trend, you know, all the more reason to be, uh, to be tight from the get-go.
Speaker 2:Well, Jim, I think that about, uh, wraps it up, uh, for us on this topic. Uh, I want to thank you for providing, uh, a lot of your invaluable insights. Um,
Speaker 3:My
Speaker 2:Pleasure. We would like to thank A A H L A for allowing us to speak today about an issue that is only gonna, uh, increase in frequency in fervor as healthcare costs rise and regulations continue to be promulgated in an already highly regulated field. Um, I've heard it mentioned multiple times that healthcare is the most regulated, uh, field, um, next to nuclear energy. So, um, I'm sure US healthcare attorneys are, are coming for that and maybe we'll beat nuclear energy one day. Uh, there's a lot of regulations, I'm sure constant changes. So thank you so much everybody, and, um, have a great day.
Speaker 1:Thank you for listening. If you enjoyed this episode, be sure to subscribe to a H L A, speaking of health law wherever you get your podcasts. To learn more about a H L A and the educational resources available to the health law community, visit American health law.org.