Hospital Audits

Provider payment integrity policy for post-payment audits

Humana operates an audit program to detect, prevent and correct fraud, waste and abuse. To further this program, Humana conducts audits on prepayment and post-payment bases. Physicians and other health care providers have the right to dispute results of audits performed by internal Humana teams or Humana vendors if they disagree with the findings.

Post-payment audit process overview

Humana or its designee has the right to conduct audits of health care provider records related to services rendered to Humana members. The clinician must allow Humana access to the medical record and billing documents to conduct audits.

Patient consent may be required to release the requested information. Please ensure that you have obtained consent in accordance with all applicable laws and regulations before releasing the requested records. Health care providers who believe an additional release authorization for an audit is necessary should obtain from Humana members their authorization for release of the medical records to Humana, along with the clinician’s consent-to-treatment forms, or the requirement will be waived if permitted by applicable law.

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

Humana utilizes, but is not limited to, the resources below to ensure that reviews are conducted in a fair manner. These are widely acknowledged national guidelines for billing practices and support the concept of uniform billing for all payers. A health care provider’s order must be present to support all charges, along with documentation to support the diagnosis and services or supplies that were billed. If there is no specific rule related to a charge in question or a participation agreement does not exist, Humana will employ:

  • Centers for Medicare & Medicaid Services (CMS) billing guidelines as stated in Medicare provider reimbursement manuals.
  • Humana policies, including medical coverage policies and code-editing policies.
  • National Uniform Billing Guidelines from the National Uniform Billing Committee.
  • American Medical Association Current Procedural Terminology (CPT®) guidelines.
  • ICD-9-CM Official Guidelines for Coding and Reporting or its successor.
  • American Association of Medical Audit Specialists National Health Care Billing Audit Guidelines.
  • Industry standard utilization management criteria and/or care guidelines.
  • UB-04 Data Specifications Manual.
  • American Hospital Association.
  • American Medical Association Coding Clinic Guidelines and Charge Master Guide guidelines as they relate to and define services billed and any other generally accepted industry standard guidelines.

Provider Payment Integrity (PPI) audits look for overutilization of services or other practices that directly or indirectly result in unnecessary costs to the health care industry, including the Medicare program. Examples include, but are not limited to:

  • Improper payment for services.
  • Payment for services that fail to meet professionally recognized standards/level of care.
  • Charges in excess or selection of the wrong code(s) for services or supplies.
  • Billing for items or services that should not have been or were not provided based on documentation supplied.
  • Unit errors, duplicate charges and redundant charges.
  • All required documentation is not present in the medical record.
  • Experimental and investigational items billed.
  • Items not separately payable, such as routine nursing, capital equipment charges, etc.

These audits also confirm that:

  • The most appropriate and cost-effective services and supplies were provided.
  • The records and/or documentation substantiate the setting or level of service that was provided to the patient.

On-site audits

An on-site audit allows an auditor to visit a health care provider to review medical records and billing documents in person. Humana has the following on-site audit guidelines:

  • A provider representative may be present during the audit process.
  • Humana or its designee will notify the health care provider of the intent to audit a claim.
  • The clinician will need to submit to Humana or its designee a copy of the itemized bill, if requested, within 30 days of the date requested. This should be submitted before the audit occurs.
  • Humana or the designee will contact the provider audit representative to schedule the audit. Health care providers 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. If a scheduled date is not confirmed by the clinician within 30 days of the initial request, Humana or the designee will attempt to contact the facility via phone, email or letter. If there is still no response, two additional attempts will be made (30 days apart). If Humana or its designee is still unsuccessful at scheduling a date for the onsite audit after these attempts, a technical denial will be issued. Once the audit has been scheduled, the technical denial will be reversed and the claim will be repaid.
  • Humana or the designee will notify the health care provider of the audit results via letter or by conducting exit conferences within 30 days from the date Humana or its designee completes the audit (or on an alternative agreed-upon date).
  • The health care provider will have 30 days from the date he/she receives Humana’s findings letter to dispute the audit results in writing. Please see the provider payment integrity clinical audit dispute process.

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

With respect to the audited claims, the health care provider will need to refund any amount Humana has overpaid within the time frame required by applicable state law or, absent a state law requirement, within no less than 45 days following receipt of notification from Humana of such overpayment.

Desk audits

A desk audit allows the health care provider to submit medical record and billing documentation to Humana or its designee. The desk audit process includes the following steps:

  • Humana may conduct reviews of claim payments within 18 months of the original date of payment or such other period as may be required or allowed by applicable law.
  • Humana may request medical records, itemized bills and substantiating documentation to support these reviews.
  • Health care providers should send copies of requested documentation within 30 days of receipt of the request.
  • For information on payment for copying fees, please refer to the provider payment integrity policy for medical records management.
  • Requested documentation can be submitted to Humana in various ways. Please refer to the provider payment integrity policy for medical records management.
  • In the event a health care provider does not submit or refuses to provide a medical record, he/she may receive a technical denial. Please refer to the provider payment integrity policy for technical denial.
  • If Humana determines that a coding and/or payment adjustment is applicable, the health care provider will be informed of the desk-audit findings by letter and may dispute the results within 30 calendar days from the date of the letter. Please refer to the provider payment integrity clinical audit dispute process.
  • With respect to audited claims, the health care provider shall refund to Humana any amount Humana has overpaid within the time frame required by applicable state law or, absent a state law requirement, within 45 days following the receipt of notification from Humana of such overpayment.