Audit services - Chapter 11, 2022 UnitedHealthcare Administrative Guide

Audit services develops and implements audits designed to identify billing and coding inaccuracies (see Chapter 17: Fraud, Waste and Abuse (FWA) for examples of potentially fraudulent, wasteful or abusive billing). Audit programs are developed in response to identified overpayment risk and include comprehensive research of critical claim elements, including medical records, itemized bills and manufacturer invoices. We conduct audits in conjunction with applicable federal or state regulations, national guidelines and contract terms.

UnitedHealthcare may use external vendors to conduct the audits. Audits may be conducted onsite or remotely.UnitedHealthcare may use external vendors to conduct the audits. Audits may be conducted onsite or remotely.

Not all requests for records are considered an audit. We also request documents to conduct claim reviews to help ensure proper reimbursement. Refer to Chapter 10: Our claims process of the guide for information on claim reviews.

Access

Our auditors notify you of our intent to audit a claim by notifying your appropriate representative. As the health care provider, you are responsible for:

• Sending a copy of the medical record, itemized bill, bill breakdown and/or other requested documentation within the time frame specified in the intent to audit letter.
• 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 otherwise specified in your Agreement. 

In addition, for onsite audits, you are responsible for:

• Cooperating in a timely manner to allow audit scheduling within 30 calendar days of the scheduling request.
• Coordinating the audit location.
• Providing the auditor access to the medical records, department charge sheets, itemized bills, other documentation and any applicable 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 Agreement.
• Not imposing time limitations on our right or ability to audit, unless otherwise stated in the Agreement or by state/federal law.

Audit findings

When the audit is complete, the auditor notifies you of any findings and requests an overpayment refund. If an overpayment has been identified, the auditor will request an overpayment refund.

• Refund Remittance - You must remit the overpayment amount within 30 calendar days of receipt of the overpayment refund request, or as required by state or federal law.
  
• Audit Findings - If you disagree with the findings, you may submit notification of the disagreement within the time frame outlined in the overpayment refund request. The notification must clearly identify the items of disagreement and include any relevant documentation to support your position.
  
• Disagreement Resolution - We respond to audit disagreements in writing, according to the terms of your contract and/or applicable state law. If you are not satisfied with our response, you may use other applicable dispute resolution procedures outlined in your contract or this guide.
• 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 45 calendar days from the date of the refund request, except when:
  • You have already remitted the amount due.
  • You have provided written notification of disagreement with the audit findings within the 45-calendar-day repayment period.
  • Your Agreement or state law says otherwise.