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Anthem Audits

Anthem Audits Can Present Substantial Risks for Healthcare Providers. Here’s How We Can Help

If you bill Anthem on a regular basis, you can expect to face an audit sooner or later. Anthem regularly audits participating healthcare providers to assess their billing compliance. While facing an audit might not seem like a big deal, these audits can present significant risks. Even if your business or practice is in compliance, mistakes during the audit process can lead to substantial liability. As a result, an informed and strategic approach is critical, and targeted providers must be prepared to proactively resolve any issues that arise.

Are you preparing for an Anthem healthcare billing audit? If so, we can help. We are a team of former federal agents who have extensive experience on both sides of healthcare billing compliance audits and investigations. We are intimately familiar with Anthem’s billing requirements and auditing procedures, and we have a proven track record of helping providers avoid unnecessary liability for perceived billing violations.

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Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

Did You Receive an Audit Letter from Anthem?

If you have received an audit letter from Anthem, it is important that you begin working immediately to plan your next steps. Once you receive an audit letter, the clock starts ticking. Anthem only gives providers a limited amount of time to respond to these letters; and, if you don’t respond in time, Anthem can treat this as grounds to deny any claims that are subject to review.

But, while it is important that you respond in a timely manner, you also need to plan your response carefully. Unnecessarily providing information or access to Anthem’s auditors can significantly increase the risks of facing an audit. Just like other types of healthcare audits, Anthem audits can—and often do—lead to unnecessary and unjustified penalties. To make sure this doesn’t happen, you need to ensure that you are doing everything necessary to protect your business or practice during the audit process.

What To Expect (and What Not to Expect) During an Anthem Audit

What can you expect during an Anthem audit? These audits are high-risk procedures for participating providers. If you don’t engage in the process proactively and effectively, you can expect to face recoupments (or “reversals”) and other penalties as a result.

When facing an Anthem audit, knowing what not to expect is important as well. With this in mind, here are some of the highlights of what you need to know:

What to Expect: Anthem Will Conduct a Comprehensive Review of Your Business’s or Practice’s Billing Records

Anthem’s audits tend to be extremely comprehensive. This is because audits are an important profit center for Anthem and other health insurers. When auditing your business or practice, Anthem will be looking for any and all grounds to impose recoupments and take additional steps to ensure that it does not issue overpayments to your business or practice for services provided going forward.

What Not to Expect: Anthem Will Not Give You the Benefit of the Doubt

When it is unclear whether a particular billing is compliant, Anthem will not give you the benefit of the doubt. This is one of several reasons why it is critical that providers play a proactive role in the audit process. At Fortis, we play this role on behalf of our clients to ensure that our clients do not face unwarranted penalties.

What to Expect: Anthem’s Auditors Will Err on the Side of Assuming Noncompliance

Just as Anthem will not give you the benefit of the doubt, its auditors will err on the side of assuming noncompliance. If Anthem’s auditors cannot confirm compliance with the documentation you provide, they will treat this lack of documentation as evidence that the billings in question are fraudulent.

What Not to Expect: Anthem’s Auditors Will Not Work With You Unless You Intervene

Since one of the primary goals of an Anthem audit is to impose as much recoupment liability as possible, Anthem’s auditors will not work with you unless you intervene. If you allow them to examine your business’s or practice’s billing history unchecked, they will do so—and, if they encounter any ambiguities, they will simply assume noncompliance and move on.

What to Expect: Anthem Will Impose Penalties for Suspected Noncompliance

If Anthem’s auditors determine that you have overbilled for medical services, supplies, tests, or other billables, Anthem will immediately impose penalties for suspected noncompliance. This, too, is one of the many reasons why providers need to engage a team of experienced professionals to intervene and manage the audit process.

What Not to Expect: Anthem Will Not Hesitate to Exclude Your Business or Practice from Future Billings

Once Anthem determines that working with a particular provider is more trouble than it’s worth, Anthem will not hesitate to exclude the provider from future billings. If, through the audit process, Anthem determines that your business or practice presents a substantial risk of ongoing noncompliance, it may simply choose not to work with your business or practice going forward.

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Spotlight: 7 Common Billing Issues Uncovered During Anthem Audits

All types of billing violations can lead to recoupments and other penalties during Anthem audits. But, in our experience, some violations tend to be more common than others. For example, here are seven issues that we routinely see come up during Anthem audits:

  • Failure to Follow Appropriate Intake, Transfer, and Discharge Procedures – Anthem requires that providers strictly follow its intake, transfer, and discharge procedures in order to bill for patient services.
  • Inadequate Patient Documentation – Inadequate patient documentation and medical records is among the leading causes of payment reversals and denials during Anthem audits.
  • Inadequate Documentation of Medical Necessity – Along with inadequate patient documentation, inadequate documentation of medical necessity can lead to reversals and denials as well—even if the services in question were in fact medically necessary.
  • Inadequate Internal Training and Billing Protocols – Inadequate internal training and billing protocols can leave providers ill-equipped to maintain an effective Anthem billing compliance program.
  • Inadvertent Billing and Coding Errors – While the vast majority of providers’ billing errors are inadvertent, this does not stop Anthem from imposing substantial penalties for noncompliance.
  • Recordkeeping Failures – As discussed above, if a provider does not have the documentation on hand needed to substantiate compliance, Anthem will treat this lack of documentation as evidence of noncompliance.
  • Technical Billing Violations – Technical billing violations are extremely common, and even mistakes such as omitting dates and signatures can lead to recoupments and denials during Anthem audits.

Although none of these issues are inherently indicative of billing fraud, they are all issues that can—and do—lead to problems during Anthem audits. While these issues can be fully addressed during the audit process in many cases, it is up to participating providers to insert themselves into the process before it’s too late.

FAQs: Avoiding Unnecessary Consequences During an Anthem Audit

What Should I Do if I Received an Audit Letter from Anthem?

If you have received an audit letter from Anthem, responding to the letter needs to be your top priority. If you fail to respond in time (or if you respond improperly) this could lead to payment reversals, denials, and other consequences that could have been avoided. Engaging a consulting firm to assess your audit risk is the first step.

How Can I Avoid Payment Reversals and Denials During an Anthem Audit?

Avoiding payment reversals and denials during an Anthem audit requires an informed, proactive, and strategic approach. Unless you convince Anthem’s auditors otherwise, they will treat anything less than full documentation of compliance as evidence of noncompliance.

What if My Business or Practice Has Overbilled Anthem?

If your business or practice has overbilled Anthem, this is an issue that you will need to address proactively during the audit process. While this can be a risky situation, our team has experience helping clients avoid serious penalties in this scenario.

Do I Need to Engage an Outside Billing Compliance Consulting Firm for an Anthem Audit?

Engaging an outside billing compliance consulting firm for an Anthem audit is strongly recommended. Anthem audits present significant risks, and engaging a team of experienced professionals to deal with Anthem’s auditors on your behalf can be critical for avoiding unnecessary consequences. Since Anthem audits often result in penalties that could have been avoided, engaging an experienced consulting firm can be the most cost-effective approach for targeted providers.

What if I Disagree with Anthem’s Findings After a Healthcare Billing Audit?

If you disagree with Anthem’s findings after a healthcare billing audit, you can challenge Anthem’s findings on appeal. However, it is best to avoid the need for an appeal whenever possible. At Fortis, we manage the healthcare billing audit process on behalf of our clients, and we have a proven track record of securing favorable results without the need for an appeal.

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Discuss Your Anthem Audit with a Senior Consultant at Fortis for Free

Is Anthem auditing your healthcare business or practice? If so, we can help, and we strongly encourage you to contact us for more information. To speak with a senior consultant at Fortis in confidence as soon as possible, please call 866-808-4160 or request a free initial consultation online today.