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