Are clinical audits and recoupement of funds increasing?

Big data is being used by insurers to aggregate and analyze clinical and financial information in order to reduce utilization of psychiatric services and to recoup funds paid out. Anthem uses Sante Analytics, an independent data analytics firm. Other large payers either outsource or insource big data analytics to scrutinize clinician’s billing and service delivery with the same objective in mind.

It is unclear how extensive this practice is. Most—but not all–of the data we have gathered is anecdotal.

One area of scrutiny is start and stop times. Two Blue Cross Plans (Wyoming and Michigan) audit for start and stop times for 90834 and 90837.

Anthem of Ohio audits psychological testing services (CPT codes 96101, 96116, 96118, and 96125) provided to Medicare beneficiaries. These codes call for start and stop times for both face-to-face time with the patient and separately the time spent interpreting and preparing the report. Anthem has taken back funds when their audits found that the time spent was not documented according to their standards.

(Most forms in the eRecord accommodate recording start and stop times. We also have a report–the Charges with Coverage report–that can be used for a self audit as it shows for each payer the services billed and the start and stop times for services rendered.)

We would like to provide a more comprehensive report on this issue soon. If you have been audited by an insurance company and would like to share your experience please email in me at geoff.gray@carepaths.com.