Hospital Audits

Overview:

Humana or its designee has the right to conduct audits of provider records related to services rendered to Humana members. The hospital must allow Humana access to the hospital’s records to conduct audits at no charge.

The Treatment Payment and Healthcare Operations (TPO) exception under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (45 CFR 164.506) allows the release of medical records containing protected health information without any additional authorization for the purpose of payment of health care claims. If the hospital believes that any additional release authorization for an audit is necessary, the hospital shall obtain from Humana members their authorization for release of the medical records to Humana, along with the hospital’s consent to treatment forms, or will waive the requirement if permitted by applicable law.

This audit provision supersedes the hospital’s internal audit policy and shall survive the termination or expiration of the hospital’s provider agreement with Humana.

If there are no specific rules related to a charge in question or a participation agreement does not exist, Humana will employ CMS billing guidelines as stated in the Medicare Provider Reimbursement Manual, National Uniform Billing Guidelines along with American Medical Association Current Procedural Terminology (CPT®) guidelines, National Health Care Billing Audit Guidelines, Coding Clinic Guidelines, and Charge Master Guide guidelines as they relate to and define services billed. Humana utilizes these resources to assure that audits are conducted in a fair manner as these are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. A provider’s order must be present to support all coding and charges, along with documentation to support the service or supply that was administered to the patient.

On-site Audits:

An on-site audit allows an auditor to visit a hospital to review the medical record in person. Humana has the following on-site audit guidelines:

• A hospital representative may be present at any time during the audit process.
• Humana’s audit department will notify the hospital of the intent to audit a claim within 180 days from the last payment for Chart Audits, or 18 months for DRG and Short Stay Audits, via “letter of intent to audit”.
• The hospital will provide the Humana audit department with a copy of the itemized bill, if requested within 30 days of the date requested. This will be submitted before the audit occurs.
• Humana will contact the hospital’s audit representative to schedule the audit. Hospitals should respond to a scheduling request within 30 days of receipt of the request and schedule the audit on a mutually agreed date and time.
• Humana will notify the hospital of the audit results via letter or by conducting exit conferences with the hospital within 30 days from the date Humana completes the audit (or upon an alternative agreed-upon date).
• The hospital has 30 days from the date Humana completed the audit and submitted findings to the hospital to appeal, in writing, the audit results. If the hospital wishes to appeal after Humana has requested an overpayment, the hospital shall contact Humana financial recovery customer service at the address listed below:

  Humana Financial Recovery Appeals

  P.O. Box 14279

  Lexington, KY 40512-4279

The hospital should receive a response to the appeal within 30 days of receipt of the appeal. Second level appeals should be made within 30 days of the date of the first level appeal results. Second level appeals also go to Humana financial recovery customer service at the address listed above. A response will be provided within 30 days.

If requested by Humana, the hospital will resubmit a corrected claim within 45 days following the exit conference in order to receive additional reimbursement for audited claims.

The hospital will refund any amounts as determined by the audit that Humana has overpaid to hospital with respect to the audited claims within the time frame required by applicable state law or, absent a state law requirement, within no less than 45 days following the hospital’s receipt of notification from Humana of such overpayment.

Desk Audits:

A desk audit allows the hospital to submit medical record documentation to Humana or its designee. The purpose of the desk audit includes, but is not limited to, confirming the following:

• The service meets Humana’s definition of "medically necessary."
• The service was billed and/or coded correctly.

The desk audit process includes the following steps:

1. Humana’s audit department will notify the hospital of the intent to audit a claim within 18 months from the original date of payment or such other period as may be required or allowed by applicable law.
2. Humana will request copies of medical records at no charge to Humana within 30 days of the hospital’s receipt of the request.
3. Payment for copying fees shall be made at the Centers for Medicare & Medicaid Services (CMS) rate of 12 cents per page or the contracted rate per the provider agreement upon receipt of the invoice with medical records. Humana reserves the right to cancel the order for the medical record if the fees are greater than 12 cents per page.
4. Should a hospital not provide the medical record, or refuse to provide the medical record, the hospital may receive a technical denial.
5. If Humana determines that a coding and/or payment adjustment is applicable, the hospital will be informed of the desk audit findings via a letter. If the hospital disagrees with the adjustment, the hospital may request a review of the desk audit findings within 30 calendar days from the date of the letter. Appeal instructions are provided within the findings letter.
6. After the initial 30-day appeal time frame, if no appeal is made, Humana will set up the overpayment and send a letter to the hospital requesting the refund.
7. The hospital may wish to appeal after the initial 30-day appeal time frame. Please see Financial Recovery Policy for Audit Appeals.
8. The hospital shall refund to Humana any amounts as determined by the audit that Humana has overpaid to the hospital with respect to the audited claims within the time frame required by applicable state law or, absent a state law requirement, within no less than 45 days following the hospital’s receipt of notification from Humana of such overpayment.

If the records are not sent in after three requests, a technical denial will be issued. The third request letter will explain that a technical denial will be issued if records are not received within 15 calendar days. If the records are not received, Humana’s financial recovery department will enter a technical denial in the system and send a request for the entire paid amount for the stay. The hospital then has 15 additional days to send in records or the amount requested will be deducted from future payments.