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Cigna Audits

Cigna Audits Present Significant Risks for Healthcare Providers that Aren’t Prepared to Manage the Process Effectively

If you are preparing for a Cigna audit, it is important to know what you should (and shouldn’t) expect during the process. Similar to other types of medical billing audits, these audits present significant risks for healthcare providers, and many providers find themselves facing unjustified payment reversals (or “recoupments”) as a result of flawed coverage determinations. Cigna audits can lead to other adverse consequences as well—including coverage exclusions and referrals for healthcare fraud investigations—so targeted providers cannot afford to take chances.

At Fortis, we assist healthcare providers with managing Cigna audits with a focus on avoiding unnecessary consequences. Facing unnecessary consequences is a very real concern, as auditors err on the side of reversing payments and denying pending claims when providers cannot provide clear evidence of compliance. Auditors make mistakes as well; and, if providers aren’t prepared to identify and effectively address these mistakes during the audit process, they can find themselves needing to file an appeal.

Our Former HHS OIG Agents Protect Healthcare Providers During Cigna Audits

With a team that includes former agents with the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), we have deep experience in the area of medical billing compliance. We know the types of issues that can lead to problems during billing audits, and we also know what providers can do to address these issues without inviting additional scrutiny or triggering unnecessary liability. If your practice is facing a Cigna audit, we can help, and we can get to work immediately if necessary.

10 Key Facts About Cigna Audits for Healthcare Providers

Preparing effectively for a Cigna audit requires informed decision-making, and targeted providers must have a clear understanding of what they need to do to protect themselves during the process. At Fortis, we provide our clients with the advice and insights they need while working proactively to steer their Cigna audits toward favorable resolutions.

What do you need to know if you are facing a medical billing audit from Cigna? Here are 10 key facts for healthcare providers:

1. Cigna Audits Can Lead to Significant Revenue Loss

For most healthcare providers, the primary risk of facing a Cigna audit is the risk of revenue loss. Through the audit process, Cigna can both reverse previous payments and deny payment for pending claims. Cigna will also impose prepayment review for future claims if an audit uncovers systemic compliance failures—and this can delay payments by several months.

2. Cigna Audits Also Present Other Risks

Along with revenue-related risks, Cigna audits present other risks as well. For example, if Cigna determines that instituting prepayment review isn’t enough to compel compliance, it can exclude providers from submitting future billings. If a Cigna audit uncovers apparent evidence of intentional billing fraud, Cigna may also make a referral to the HHS OIG for further investigation.

3. Unjustified Allegations of Noncompliance Are Common

During Cigna audits, unjustified allegations of noncompliance are common. As we discussed above, when in doubt, Cigna’s auditors will err on the side of making a determination of noncompliance. As we also discussed above, Cigna’s auditors make mistakes; and, if providers don’t catch these mistakes, they can face unnecessary financial consequences.

4. Being Prepared to Affirmatively Demonstrate Billing Compliance is Key

Due to these concerns, being prepared to affirmatively demonstrate billing compliance is key. Even when providers are confident in their billing compliance programs, they cannot afford to simply let a Cigna audit run its course. Instead, they must use their compliance documentation to show that their billings are valid, and they must intervene when auditors reach flawed conclusions.

5. Numerous Issues Can Lead to Payment Reversals and Other Penalties

There are numerous issues that can lead to payment reversals and other penalties during a Cigna audit. Being aware of these issues is key, and providers should proactively assess their risk before their audits begin. Some examples of common issues uncovered during Cigna audits include:

  • Billing for services that aren’t medically necessary
  • Billing for services provided by unlicensed providers
  • Double-billing
  • Improperly billing for consultations, referrals, or discharges
  • Improperly billing for home health, hospice, telehealth, or telemedicine services
  • Phantom billing (billing for services or items not provided)
  • Upcoding, unbundling, and other coding violations
  • Failing to maintain adequate and legible patient records
  • Failing to maintain appropriate recordkeeping procedures
  • Submitting false or forged certifications, patient records, or other documents

6. Avoiding Unwarranted Consequences Requires Proactive Efforts

Regardless of a provider’s compliance record, avoiding unwarranted consequences requires proactive efforts during a Cigna audit. At Fortis, we undertake these efforts on behalf of our clients so that they can rely on our expertise while they remain focused on serving their patients.

7. Providers Must Be Able to Spot Flaws in the Audit Process

When auditors make mistakes, spotting these mistakes is essential for keeping the audit on course. As a result of our intimate familiarity with the relevant auditing rules, requirements, and procedures, we are able to promptly intervene in our clients’ audits as necessary.

8. Even Inadvertent Mistakes By Individual Employees Can Present Risks

Many providers assume that uncovering intentional billing fraud is the primary focus of an audit. While this may or may not be true, it is important to understand that even inadvertent mistakes by individual employees can present risks. When conducting audits, Cigna looks for evidence of both intentional and unintentional billing violations—and both can lead to payment reversals, payment denials, and other penalties.

9. An Unfavorable Audit Determination Will Increase the Risk of Another Audit

Receiving an unfavorable audit determination isn’t the end of the process. If Cigna uncovers issues with a provider’s medical billings during an audit, this will significantly increase the likelihood of a follow-up audit in the future.

10. Providers Must Prioritize Compliance Before, During, and After Cigna Audits

With all of these concerns in mind, it is clear that healthcare providers must prioritize compliance before, during, and after their Cigna audits. At Fortis, we take a comprehensive approach to protecting our clients that includes preparation, intervention, and response. Our former HHS OIG agents and other medical billing experts can use their experience to guide you safely through the audit process, and we can assist with resolving any post-audit issues as necessary.

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FAQs: Protecting Your Healthcare Practice During a Cigna Audit

Why is Cigna Auditing My Healthcare Practice?

While Cigna audits participating providers as a matter of course, it also conducts targeted audits in response to billing anomalies, complaints from patients and family members, and information received from federal healthcare and law enforcement agencies. Understanding why your practice is being audited is a key first step toward making informed decisions.

Should I Be Concerned if I Am Facing a Cigna Audit?

All Cigna audits present risks. As a result, healthcare providers targeted in these audits need to prioritize their response. At Fortis, we help minimize providers’ risk during their Cigna audits by using our experience, insights, and expertise to manage the audit process on their behalf. However, there are no guarantees, and billing errors can expose providers to substantial liability. Once we examine your practice’s relevant billings, then we can provide an accurate risk assessment and help you develop an effective strategy for dealing with Cigna.

How Can I Avoid Payment Reversals and Denials During a Cigna Audit?

Avoiding payment reversals and denials during a Cigna audit involves working proactively to affirmatively demonstrate billing compliance during the audit process. If you can convince Cigna’s auditors that your practice’s billings are fully compliant, then you should not be at risk for payment reversals, denials, or other penalties.

Can a Cigna Audit Lead to Exclusion from Future Billing?

Yes, Cigna audits can lead to exclusion from submitting future billings. If Cigna determines that a provider’s history of non-compliance presents too great a risk for the company going forward, it may simply choose not to deal with the provider. If your practice is at risk for exclusion, our consultants can assist with developing a corrective action plan and taking other necessary steps to preserve your practice’s ability to bill Cigna.

Should I Engage a Consulting Firm to Handle My Healthcare Practice’s Cigna Audit?

Due to the substantial risks that Cigna audits can present for both compliant and non-compliant healthcare providers, working with an experienced consulting firm during the audit process is key. At Fortis, we have a proven record of success protecting healthcare providers during medical billing audits, and we can use our experience to your advantage.

Discuss Your Cigna Audit with a Senior Medical Billing Consultant at Fortis

Are you facing a Cigna medical billing audit? If so, we strongly encourage you to contact us for more information. We provide complimentary consultations, and a senior medical billing consultant at Fortis can help you make informed decisions about your next steps. To schedule an appointment as soon as possible, please call 866-808-4160 or tell us how we can get in touch online today.