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Requests for Documentation from Health Insurance CarriersThe Billing Compliance Office has noted a marked increase in the number and frequency of requests for documentation from health insurance carriers. Specific requests for documentation from Medicare Part B have centered on the following: Electronic Media Claims (EMC) audits – These reviews are conducted annually. A random sample of electronically submitted services are reviewed to insure that proper documentation such as “signature-on-file” is available. Health Professional Shortage Area (HPSA) audits – These reviews are conducted randomly to monitor whether services were actually provided within a designated HPSA area. Comparative Performance Reports (CPR) audits – These reviews of documentation are very specific in nature. The carrier is required to review services provided by physicians when those services exceed a national or regional threshold. Benefit Integrity audit – The carrier will require documentation for all services that are suspected to be fraudulent or abusive in nature. The carrier is required to respond to all customer inquires made regarding the level of service provided. Any insurance carrier may request documentation in their efforts to compile national or local data. The Billing Compliance Office must be notified within one business day of all requests for documentation received from insurance carriers. The Billing Compliance Office will assist with obtaining the documentation and will also assist with formulating the response to the carrier. Your cooperation is appreciated. |