Learn how to maneuver with prepayment reviews.
Q: I am an out-of-network provider for a large commercial insurer. For months, all my claims with this insurer have been in prepayment review. If I submit a claim after 30 days, I get a letter asking for notes to get paid. The turnover time now is 3 months, and I have submitted more than 200 claims with notes. I have called to inquire when this prepayment review will end, but I never receive any clear answers. Any advice?
A: We usually see these kinds of letters after a payer audits a provider and claims there are "problems" (for instance, upcoding, unbundling, medically unnecessary tests, etc.) and possibly will demand a refund from the provider. Once the parties resolve the dispute, the payer typically wants to see the records before paying, to ensure that the "problems" identified in the audit are not recurring. At least that's what the payer claims.
This is a form of harassment. If the provider enters into a participating provider agreement with the payer, the agreement usually will include a provision allowing the payer to ask for records as part of a prepayment review. As a nonparticipating provider, you should argue that you never entered into this agreement and that if the payer has not found any issues to date, the prepayment review process should stop because it creates an administrative and economic burden on the provider.
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Answers to readers' questions were provided by Susan Childs, Evolution Healthcare Consulting, Rougemont, North Carolina; A. Michael La Penna, The La Penna Group, Grand Rapids, Michigan; and Barry B. Cepelewicz, MD, JD, Meiselman, Denlea, Packman, Carton & Eberz, White Plains, New York. Send your practice management questions to firstname.lastname@example.org