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Humana Audits

Our Medical Billing Experts Help Healthcare Providers and Pharmacies Effectively Manage the Risks of Humana Audits

Like all medical billing audits, Humana audits present significant risks for healthcare providers and pharmacies. While Humana’s auditors thoroughly review payees’ patient and billing records for compliance, they also err on the side of reversing and denying payments when compliance cannot be confirmed. As a result, it is essential that targeted healthcare providers and pharmacies play an active role in the audit process.

At Fortis, we manage Humana audits on behalf of our clients. Once engaged, we work quickly to assess our clients’ risk and develop custom-tailored audit defense strategies. While a Humana audit isn’t necessarily an adversarial process, during the process, Humana’s and payees’ interests are not aligned. As a result, payees must focus on protecting themselves, and they must be prepared to take action when necessary.

Medical Billing Consultants Who Can Overcome the Risks and Challenges of Humana Audits

Our medical billing consultants have extensive experience advising healthcare providers and pharmacies during Humana audits. We have a clear understanding of not only the risks these audits present, but also the challenges involved in managing these risks effectively. Our team works diligently to assess each client’s risks on a case-by-case basis, and then we rely on our experience to execute custom-tailored defense strategies focused on helping our clients avoid payment reversals and other negative outcomes.

When you choose our team to manage your healthcare practice’s or pharmacy’s Humana audit, you will work directly with our senior medical billing consultants throughout the process. Our consultants will help you make informed decisions while communicating with Humana’s auditors on your behalf. If we can use your practice’s or pharmacy’s records to demonstrate full compliance, we will. If there are issues that we need to address, we will work to address them proactively so that any consequences are no greater than absolutely necessary.

Put our highly experienced team on your side

Dr. Stephen Taylor

DOL Consultant

Roger Bach

Former Special Agent (OIG)

Chris Quick

Former Special Agent
(FBI & IRS-CI)

Kevin Smith

Former Assistant Regional Inspector General

Michael Koslow

Former Supervisory Special Agent (DOD-OIG)

James Hunt

Former Special Agent-in-Charge (DEA)

10 Key Steps for Effectively Managing a Humana Medical Billing Audit

Avoiding unnecessary consequences during any medical billing audit requires an informed and strategic approach. Humana audits are no exception. With this in mind, here are 10 key steps we take to help healthcare providers and pharmacies that are facing Humana audits:

1. Conducting an Internal Medical Billing Compliance Analysis

One of our first priorities is to assess our client’s risk in their audit. This involves quickly conducting an internal medical billing compliance analysis. Once we know what (if anything) Humana’s auditors are going to find, then we can help our clients make informed decisions about how best to handle the audit process.

2. Locating All Relevant Billing Records, Patient Records, and Compliance Documents

When conducting our internal medical billing compliance analysis, we will also take stock of all relevant billing records, patient records, and compliance documents. Providers and pharmacies need to have these available during their Humana audits, and being able to quickly provide proof of billing compliance can help to facilitate an efficient and favorable resolution.

3. Anticipating Potential Issues During Humana’s Audit

When conducting audits, Humana looks for any and all evidence of violations that can justify payment reversals and other penalties. We anticipate the issues that are likely to come up during our clients’ audits so that we can address them proactively. This includes (but is by no means limited to) common issues such as:

  • Billing for services not rendered or items not supplied
  • Billing for supplied services or items without adequate documentation of medical necessity
  • Billing for services rendered by another provider or facility (or billing for services rendered by an unlicensed provider under a licensed provider’s name)
  • Using incorrect CPT and HCPCS codes to bill for non-covered services
  • Upcoding, unbundling, misusing modifiers, and double-billing
  • Altering, forging, or falsifying documentation to support fraudulent billings

While these issues, among others, can present risks for healthcare providers and pharmacies during Humana audits, there are also strategies for avoiding unnecessary consequences. At Fortis, we rely on our extensive experience to execute these strategies on behalf of our clients.

4. Establishing a Response Team and Lines of Communication

It is critical that healthcare providers and pharmacies take a structured approach to responding to their Humana audits. We build structure by establishing a response team and clear internal and external lines of communication. By clearly establishing everyone’s role and ensuring that all communications with Humana’s auditors flow through our team, we are able to help ensure that miscues and misstatements do not lead to unnecessary consequences.

5. Making Contact with Humana at the Outset of the Audit

Effective communication is essential during the audit process. To ensure that we have the information we need to advise our clients appropriately, we make contact with Humana at the outset of each audit to make clear that we are their point of contact. This way, our clients don’t have to relay messages to us, and we can respond to any concerns immediately.

6. Overseeing the Audit and Addressing Issues as They Arise

Issues during Humana audits are not uncommon. We routinely see Humana’s auditors make mistakes that lead to unjustified determinations of non-compliance. This includes (but is by no means limited to) misinterpreting and relying on outdated versions of:

  • Centers for Medicare and Medicaid Services (CMS) Medicare manuals
  • Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) guidelines
  • Humana coverage policies and provider manuals
  • ICD-10-CM Official Guidelines for Coding and Reporting
  • Medicare local and national coverage determinations

At Fortis, medical billing compliance is our specialty. We know the rules, and we know how they apply to our clients’ businesses. We use this knowledge to help ensure that auditors’ miscues do not lead to unwarranted negative outcomes.

7. Documenting Issues to Prepare for an Appeal if Necessary

While we are able to resolve issues with auditors’ methodologies and findings proactively in many cases, sometimes healthcare providers and pharmacies will be left with no choice but to file an appeal. When the need to file an appeal seems likely, we thoroughly document the relevant issues so that our clients and their counsel are prepared to take all necessary next steps.

8. Reviewing Humana’s Conclusions and Determining Next Steps

The next steps after a Humana audit can range from continuing business as usual to preparing for an appeal. Once Humana’s auditors have completed their tasks, we review their final conclusions and consult with our clients regarding the outcome of the audit process.

9. Assisting with Development of Corrective Action Plans and Other Mitigation Strategies

In some cases, developing a corrective action plan or implementing other mitigation strategies will be necessary to address medical billing violations uncovered during a Humana audit. When our clients cannot avoid consequences entirely, we focus our efforts on working with Humana to mitigate the consequences of our clients’ past mistakes.

10. Assisting with Medical Billing Compliance Program Improvements

When our clients’ audits expose shortcomings in their medical billing compliance programs, we work with them to implement all necessary improvements. Along with our audit consulting services, we provide comprehensive medical billing compliance services as well.

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FAQs: Avoiding Payment Reversals and Other Consequences During a Humana Audit

What Should I Do if I Received an Audit Notice from Humana?

If you have received an audit notice from Humana, it will be important to start preparing for the audit promptly. Humana audits can present risks for healthcare providers and pharmacies even if their billings are fully compliant, so a proactive approach is critical.

What Records Do I Have to Provide During a Humana Audit?

Humana’s auditors have the authority to issue broad requests for payees’ billing and patient records. They can also request copies of payees’ compliance documentation. But, there are limits, and it is important to make sure that you do not provide any records to Humana’s auditors unnecessarily.

What Rights Do Healthcare Providers and Pharmacies Have During Humana Audits?

Healthcare providers’ and pharmacies’ rights during Humana audits include the right to play an active role in the process and the right to scrutinize auditors’ determinations. Providers and pharmacies also have the right to engage outside consultants to oversee the audit process on their behalf.

How Can I Avoid Payment Reversals During a Humana Audit?

Avoiding payment reversals during a Humana audit requires a proactive approach to demonstrating compliance with all pertinent medical billing rules and regulations. At Fortis, we have extensive experience helping healthcare providers and pharmacies protect their revenue during the audit process.

What Can a Humana Audit Consultant Do to Help?

At Fortis, our Humana audit consultants help healthcare providers and pharmacies by taking control of the audit process and steering it toward an efficient and favorable resolution. What exactly this entails varies case by case depending on the circumstances involved. In all cases, however, our focus is on helping protect our clients’ revenue and minimizing their audit-related risk to the fullest extent possible.

Schedule an Appointment with a Humana Audit Consultant at Fortis

If you would like to speak with a Humana audit consultant at Fortis, we invite you to get in touch. Please call 866-808-4160 or contact us online to request a complimentary consultation.

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