How to Navigate Insurance Audits as a Private Practice SLP

While insurance audits are certainly something most SLPs would like to avoid, there’s always a chance you may face one in your private practice. 

But as intimidating as this might sound, it doesn’t have to be. There are a few best practices you can use in how you run your practice day-to-day that can go a long way if and when you get audited by insurance. 

First, let’s talk about why insurance companies do audits in the first place.

Why Insurance Companies Do Audits

It’s helpful to remember that insurance companies are in business to make money and/or save their employers’ money. When you understand this idea, it’s easier to understand why insurance plans may decide to audit providers to possibly recapture payouts or avoid paying future claims.  They’re primarily looking for fraud, abuse, and waste. 

Insurance companies often perform audits randomly or based on certain thresholds designated by a certain plan. There are  also times when they run reports looking for trends within geographical areas, targeting a specific discipline. 

Variations and atypical billings are often flagged for further investigation. These providers are then targeted to provide supporting documentation for claims submitted. Some examples of these outliers might be:

• Use of a speech therapy CPT code atypical for your discipline.
• Billing a higher-than-average number of visits.
• Monitoring the use of visits for policies with unlimited visits.
• The use of diagnoses and treatment doesn’t match documentation.
• Not conforming to coding guidelines.

As a provider, it’s in your best interest to establish behaviors in your practice that promote and maintain compliance all the time, even if there isn’t an audit looming for you. Increased compliance, even if it takes more time or costs a little more, means you likely avoid paying a lot more in a retroactive audit, or ensuring your future claims are paid. 

What Does an Audit Look Like?

Now that we understand why insurance companies might do an audit, let’s talk about what it looks like if it happens to you. Often, an audit will look like an insurance company withholding or stopping your current claims from processing and requesting certain documentation from you. 

This request might include documentation associated with the days of service in question or specific documents for previous dates of service. A representative of the insurance company may also schedule time to visit your office and review the documents they requested—but most providers simply have to send in the requested documentation. 

How to Avoid an Audit

Let’s first clarify this point: You can’t completely avoid audits. 

Like the IRS, insurance companies can decide to take a look at your practice’s records at any point during your client’s care. If you are in-network with a payer, the contract you signed likely listed this as a stipulation. Member contracts often give permission for insurance companies to review their health records to justify payment and maintain care. 

That said, there are a lot of ways you can audit-proof your practice to reduce the chances of being negatively impacted if you were to be audited. Here are a few best-practices you can incorporate into your daily workflow: 

Keep good data.
This is the very foundation of our training as SLPs. Your records and documentation should outline who initiated treatment, why the client is there, what you did, the support you provided, and the progress they made. 

Use an EHR/EMR system.
A HIPAA-compliant practice management system will ensure your documentation and claims align. The dates of service and procedures billed must match, which can be tricky if you’re doing all your notes and billing by hand.

Understand billing, coding, and modifier rules.
The diagnosis and CPT codes must match your written documentation, like your SOAP notes and other forms of documentation. The charges you bill must be supported by the clinical reason. Sometimes, this requires providing supporting documentation from other providers to justify your coding choices.

Understand medical necessity.
Submission of claims to insurance requires the demonstration of medical necessity. Some plans may dictate what this looks like for their specific members, but in general, your service must treat the diagnosis, be clinically appropriate, and not be provided to maintain the current status.

Understand your contract stipulations. 

One gray area that many SLPs often miss is understanding what, if any, stipulations their insurance payer contracts make about additional office staff. For instance, some contracts may not allow assistants like SLPAs, PTAs, or OTAs to treat members of a particular insurance network, which may flag an audit. Make sure you carefully read all the insurance contracts you sign and allocate your treatment staff accordingly. 

What to Do When You’re Audited

Like I mentioned before, you can do your best in your day-to-day work to avoid an audit—but there’s still a chance it might happen. If it does, don’t panic! The insurer will send a letter with clear directions for you to complete the request. Depending on the level of audit, your due process rights may be provided with directions on how to respond. 

From there, there are a few other best practices to make the process as smooth as possible: 

Cooperate. 

Getting audited isn’t fun, but if it happens, the best way to get through it is to cooperate and send the documentation they ask for. If you’ve prepared correctly and have kept accurate records, you’ll hopefully be able to get through without too much hassle. 

Upload the requested document(s) to the portal. 

Gather the requested documents and send them to the appropriate contact as directed. Most payers have a portal that they use to collect documentation during audits. This is the safest and quickest way to transmit your client’s data and get it to the right person. You can also consider taking an extra step to call the insurance directly to confirm the documents were received, and make note of the reference number the phone representative gives you.

Provide only what’s requested. 

Insurers often request documents based on dates of service. Don’t provide additional information that doesn’t support the requested dates. Doing so could be a violation of your client’s privacy, and is outside the scope of what the insurer is looking for. 

Do not edit your documents. 

If you’re using an EHR, there’ll be a record of any edits you make to your documents and when you made them. It’s important to maintain the validity of your documentation, so if you do need to make an edit to a requested document, you’ll need to ensure it’s clinically justifiable. 

Review your insurance contract. 

This document outlines your rights and responsibilities as a provider within the specific network. It’s important to note timelines and procedures that may be outlined here.

Search your state’s recoupment laws. 

Depending on the insurance type, there may be laws in your state that specify timelines to guide how long from the claim date insurance can conduct post-payment recoupment. 

Consider hiring a lawyer. Depending on the entity initiating the audit and what’s at stake, you may need to consider hiring a healthcare lawyer to help you navigate deep waters. You’ll want to determine the reason for the audit (insurance error, provider error, fraud, misconduct, etc.). If you feel out of your depth, a healthcare lawyer can help you navigate the process and limit any potential errors that might prolong the process. 

No one wants to be audited, but if you accept insurance in your practice, it’s a part of your business that you have to plan for. By following these best practices, you’ll be doing everything you can to make an audit as painless as possible, so you can continue to focus on great client care.