How to Navigate Insurance Audits as a Private Practice SLP

insurance audits slp

While insurance audits are certainly something most SLPs would like to avoid, there’s always a chance you may face one in your private practice.

But as intimidating as this might sound, it doesn’t have to be. There are a few best practices you can use in how you run your practice day-to-day that can go a long way if and when you get audited by insurance.

First, let’s talk about why insurance companies do audits in the first place.

Why Insurance Audits Happen

It’s helpful to remember that insurance companies are in business to make money and/or save their employers’ money. When you understand this idea, it’s easier to understand why insurance plans may decide to audit providers to possibly recapture payouts or avoid paying future claims. They’re primarily looking for fraud, abuse, and waste.

Insurance companies often perform audits randomly or based on certain thresholds designated by a certain plan. There are also times when they run reports looking for trends within geographical areas, targeting a specific discipline.

Variations and atypical billings are often flagged for further investigation. These providers are then targeted to provide supporting documentation for claims submitted. Some examples of these outliers might be:

  • Use of a CPT code atypical for your discipline.
  • Billing a higher-than-average number of visits.
  • Monitoring the use of visits for policies with unlimited visits.
  • The use of diagnoses and treatment doesn’t match documentation.
  • Not conforming to coding guidelines.

As a provider, it’s in your best interest to establish behaviors in your practice that promote and maintain compliance all the time, even if there isn’t an audit looming for you. Increased compliance, even if it takes more time or costs a little more, means you likely avoid paying a lot more in a retroactive audit, or ensuring your future claims are paid.

What does an audit look like?

Continue reading the full article at Pollen Magazine.

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