Humana Provider Audits

Humana will be performing audits similar to the ones that the Centers for Medicare & Medicaid Services (CMS) Recovery Audit Contractor (RAC) Auditors performed in the CMS RAC Pilot Program in 2008. Humana has been performing similar audits for years, and the process remains the same.

Humana uses internal physicians, registered nurses and certified coders, as well as contracted vendors, to conduct the audits. When medical records are requested, Humana sends a letter explaining the specifics of the audit, including the specific records that are needed and the contact information for the auditor. If the audit results in findings that vary from what originally was billed, the hospital is then sent a detailed letter explaining the variance. The hospital has 30 days to send additional information and appeal the findings, if necessary.

After 30 days, Humana receives and processes the results of the audit. If the audit reveals overpayment, Humana will send a letter to the hospital to request payment for the amount that was overpaid. If an underpayment is identified, the hospital is notified and asked to send a corrected claim in order to be paid.

If you have any questions regarding the audits, please contact Laura Kinney at lkinney@humana.com or Nicole Wilcox at nwilcox@humana.com.

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