Providers · 28 Oct 2019 0

I’m out-of-network with the payer requesting an audit. What right does the company have to audit my records?


A trending issue has popped up in my inbox and I thought I’d take a quick minute to post this crude blog article: Out of Network Behavioral Health Providers receiving Audit Requests from Non-Contracted Health Plans.

More and more audits seem to involve payers looking at psychologists who are out-of-network providers. Such psychologists may ask what gives the company the right to audit when they have no provider contract with the company. (Provider contracts typically require that you comply with the company’s audit requests.)

The answer is that while you may not have audit obligations to the payer in this situation, the patient’s contract with the company may require the patient to allow that his or her care and records be audited in order for the patient to be reimbursed or to have further care authorized. The payer might also claim that it has the right to determine if your out-of-network services met the medical necessity definition in the patient’s insurance plan. Generally, the patient’s best interest is served by complying with audit requests that are reasonably aimed at determining whether the patient received appropriate out of-network services. 

I help providers navigate such issues all the time — informed by both my payer and provider side management experience — yet I’m still surprised at the creative ways managed care organizations seek recoups, audits, and claw-backs.

Never ceases to amaze me, our industry.

We need reduction in provider burden, not an increase. Onerous paperwork and requests from payers to conform to various policies and ‘edits’ create an undue strain on our increasingly stressed delivery systems. If I can help, let me know — whether it’s making connections via my healthcare industry ‘contact book’ and/or reaching into my long list of tips/tricks to utilize in dealing with any given issue you, as providers, might be facing.

PLEASE NOTE: Legal issues are complex and highly fact specific and require legal expertise that cannot be provided by any single article. In addition, laws change over time. The information in this posting should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions regarding individual circumstances.