Total Health Law Blog
Our healthcare and business law firm often assists medical practices in responding to medical record and coding audits initiated by private and governmental payors. If a payor believes there are consistent concerns with a medical practice’s claims, the payor may place the practice under a prepayment review process. This process can be very concerning to a practice and, in some cases, can place a practice at risk of shutting down. A previous post provided an overview of standard claims processes versus a prepayment review process. Prepayment review processes are different depending on which payor you are dealing with and whether the payor is private or government. Herein, I provide a few tips for dealing specifically with TRICARE/Humana Military regarding a prepayment review process. If you have questions about an insurance audit or prepayment review process or would like to discuss this blog post, you may contact our healthcare and business law firm at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@hamillittle.com. You may also learn more about our law firm by visiting www.hamillittle.com.
In a previous blog post, I presented three tips for dealing with an audit from any payor. Those tips remain relevant for trying to end a prepayment review with TRICARE/Humana Military. The below tips are targeted specifically for dealing with a prepayment review process with TRICARE/Humana Military that is causing harm to your business due to the lack of claims being timely paid.
Tip 1: Get Your Community Liaison Involved
As a TRICARE provider, you have a Community Liaison that you can connect with via email and through the portal. Your Community Liaison is there to answer your questions and connect you with the right people. With all correspondence, I recommend having your counsel email the Community Liaison with a copy submitted through the portal letting them know you are on a prepayment review. If you have trouble getting a response from the Community Liaison, you can reach out to your region/state’s Liaison Director.
Tip 2: Advocate, Advocate, Advocate
The next step is for your counsel to advocate for why the prepayment review process should end. Remember from the last blog post, what Humana Military is looking for is that a high percentage of claims submitted are not deficient and are payable. Your compliance consultant and attorney can help ensure you make changes so that this becomes true, and, in advocating on your behalf, your attorney should explain all the steps you have done to correct the deficiencies (if there were any) or to otherwise ensure claims are accurate and supported by documentation. The next thing to show is the harm you are facing. We have had clients close to shutting down due to lack of payment. This would have resulted in hundreds of TRICARE beneficiaries being abruptly left without care. If you treat a vulnerable population, make that known! TRICARE does not want its beneficiaries left without care. Have your patients or their parents/guardians write letters supporting your practice and explaining the harm they would experience if the practice closed down.
Tip 3: Get Your Representative Involved
If you have done the above to advocate yet you are not receiving a response and/or remain on the prepayment review, get your representative involved! No representative wants to hear that veterans and their families may suffer because TRICARE is not paying promptly.
Facing an insurance audit is already scary enough, considering the treble damages available if the payor believes you to have engaged in fraud. When a prepayment review process is added, however, the risk of serious damage to a practice becomes even more imminent. If you have questions about an insurance audit or would like to discuss this blog post, you may contact our healthcare and business law firm at (404) 685-1662 (Atlanta) or (706) 722-7886 (Augusta), or by email, info@hamillittle.com. You may also learn more about our law firm by visiting www.hamillittle.com.
*Disclaimer: Thoughts shared here do not constitute legal advice.