Hospital Audit Services - Chapter 10, 2018 UnitedHealthcare Administrative Guide

We use nationally recognized billing/coding guidelines for our audits. These guidelines are from the American Association of Medical Audit Specialists in partnership with CMS. They are located on: aamas.org > Resources > Nat’l Audit Guidelines. Facility audits help to identify billing and coding errors. The audits are to identify contract risks. They include a thorough review of critical claim elements that are not on the UB-04, such as medical records and itemized bills. The audits could happen on a pre or post-payment basis. We conduct the audits onsite at your location or offsite with a designated representative. We may conduct other audits or make other record requests, in accordance with the National Hospital Billing Audit Guidelines.

Standard Percent of Charge Hospital Bill Audit

Our Standard Percent of Charge Hospital Bill Audit includes a review of medical records to support the billed charges. Inappropriate charges include:

  • An individual charge that was unbundled from a more general charge in which it is commonly included
  • A charge that is not supported by the records

Post-audit claim reconsideration reconciles overpayments or underpayments identified from the audit.

Hospital Requirements and Access

Our auditors notify the hospital of our intent to audit a claim by notifying the appropriate hospital representative. The hospital is responsible for:

  • Sending a copy of the itemized bill within 30 calendar days of the request, and/or
  • Sending a copy of the bill breakdown at the time of audit
    • The hospital notifies the auditor if the breakdown will be provided within 30 calendar days after we notify them of the audit
  • Cooperating in a timely manner
    • The auditor needs to complete the audit scheduling process within 30 calendar days of the scheduling request
  • Obtaining the member authorization to release their medical information
    • In many cases, the member signs this authorization at the time of admission
  • Waiving the fee associated with the audit or copying of records, unless specified in their facility agreement
  • Coordinating the audit location, if onsite
    • Audits are conducted either offsite or at the hospital
  • Providing the auditor with access to the medical records, department charge sheets, and any applicable hospital policy and procedure (if requested)
  • Providing our audit vendors the same access as our employee auditors
    • Vendors authorized by us are bound to our obligations under the facility agreement
  • Not imposing time limitations on our right or ability to audit, unless otherwise stated in the facility agreement or by state/federal law

Audit findings

When the audit is over, the auditor notifies the hospital of the findings. We provide the hospital representative with a copy of the audit findings, if requested. We give copy of the findings immediately if the audit is done at an offsite location.

Post-audit Procedures

  • Refund Remittance – For an undisputed overpayment, the hospital remits the amount of the overpayment within 30 calendar days of receipt of the refund request, or as required by state or federal law.
  • Disputed Audit Findings – If the hospital wants to dispute the findings, they submit notification of the dispute within 30 calendar days of receipt of the audit findings per the terms outlined in our overpayment notification letter. The notification must clearly identify the items in dispute, with the relevant authority and relevant documentation for the disputed items.
  • Dispute Resolution – We respond to notification of disputed audit findings in writing within 60 calendar days of receipt.
  • Escalated Dispute Resolution – If the dispute remains unresolved, the hospital may request a conference call to include representatives of UnitedHealthcare and our Network Management staff. Escalated dispute resolution stops recovery efforts associated with the disputed audit findings during the discussion between parties.
  • Unresolved Dispute – Either party may further pursue dispute resolution as outlined in this guide and in your agreement with us.
  • Offsets – When we issue a refund request in connection with an audit, we recoup or offset the identified overpayment, and/or disallowed charge amounts after 35 calendar days from the date of the refund request, except when the hospital:
  • Has given us amount due within the 35 calendar day repayment period
  • Has provided written notification of its dispute of the audit findings within the 35 calendar day repayment period
  • The participation agreement or state law says otherwise

Technical Denials

The hospital is required to submit, or give access to, medical records upon our request. Failure to do so may result in a technical denial. Medical records request that do not comply with our guidelines follow the technical denial process. The technical denial also consists of needing additional information, notifying the care providers, overpayment, and future actions.