May 22, 2012



I just started receiving record requests before getting paid from an insurer I participate with.  My office is not equipped to keep producing these records.  What do I do?

Dr. F


Dr. F, it sounds as though you are getting your first taste of a pre-payment review process.  Pre-payment review is a process employed by insurers to prevent payments for services the insurer believes it may have reason to deny reimbursement for services prior to paying same.  Typically a provider finds themself on prepayment review because a particular billing practice has raised a red-flag by the insurer, for instance, rendering a certain service more frequently than a similarly situated colleague.  Other times prepayment review is the result of a random selection by the insurer checking medical necessity and documentation.  Pre-payment review is different than a post-payment review; both pre and post-payment reviews are similar audit processes but a signficant difference is pre-payment is checking present claims, whereas post-payment is a retrospective review oftentimes resulting in a recoupment demand (frequently a large recoupment demand).    The most productive response to a pre-payment review, once identified, is to work to find out what documentation practices of yours are causing the flag by the insurer, and how to be removed from flag.  Because communicating with insurers is frustrating, sometimes futile, many practitioners turn to their healthcare counsel for assistance.  We work with our clients on pre-payment review by attempting to immediately isolate the flagged services and implement (with the help of coding experts) corrective documentation practices.  Compliance activity goes hand in hand with practice compliance and implementing a compliance plan to cut down on future errors, which we recommend as well to prevent pre and post-payment audits. 

If you would like assistance getting to the bottom of the record requests and moving the pre-payment process along, contact me directly at (516) 747-6700 x. 302 or Rachel Weinrib, Esq. of our office at (516) 747-6700 x. 317.



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