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United HealthCare Audits

We Help Providers Avoid Reversals and Other Penalties During United HealthCare Audits

United HealthCare is the nation’s largest healthcare payor. It administers billions of dollars in healthcare billings annually, including both private insurance billings and Medicare reimbursements. To enforce compliance, it conducts claim-by-claim audits—and these audits can present significant risks for payees.

One of the primary risks associated with facing a United HealthCare audit is the risk of reversal. If United HealthCare’s auditors determine that any claims have been paid improperly, it can seek to reverse these claims immediately. Reversals can leave providers owing more than they can afford to pay, and they can also increase the risk of facing additional scrutiny from United HealthCare’s auditors in the future.

But, United HealthCare audits can lead to other negative outcomes as well. For example, United HealthCare can impose prepayment review of future claims, and it can also exclude providers from submitting future billings. These risks make it essential for providers to take a proactive approach to their United HealthCare audits regardless of their past compliance records.

Experienced Medical Billing Consultants for United HealthCare Audits

Our medical billing consultants have extensive experience assisting providers during United HealthCare audits. All members of our team have senior-level experience, and many are former federal law enforcement agents who used to investigate healthcare fraud on behalf of the government. As a result, not only are we intimately familiar with the rules and regulations that govern healthcare providers’ billing practices, but we are also well-versed in the methodologies that auditors use to examine providers’ billings.

As a result of our background, we are able to take a proactive approach to managing our clients’ United HealthCare audits. We quickly and thoroughly assess each client’s potential exposure, and we communicate directly with United HealthCare’s auditors on each client’s behalf. Depending on the circumstances, our communications with United HealthCare might focus on demonstrating full compliance, or they might focus on acknowledging unintentional mistakes and developing a corrective action plan that mitigates any potential penalties.

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)

15 Potential Issues During a United HealthCare Medical Billing Audit

When conducting medical billing audits, United HealthCare looks for any and all forms of non-compliance. While substantive billing errors can lead to reversals (and potentially other consequences), so can technical errors such as omitting dates and other basic information. By requiring strict compliance, United HealthCare gives itself the ability to demand reversals in an extremely wide range of circumstances, and this shifts the onus to providers to show that reversals are unwarranted.

The following are 15 common examples of issues that can lead to reversals (and other penalties) during a United HealthCare audit:

  • Services or Supplies Not Provided – United HealthCare routinely demands reversals when providers’ billing records fail to demonstrate that the billed-for services, tests, medications, or supplies were actually provided.
  • NonQualifying Services or Supplies – Billing for services, tests, medications, or supplies that do not qualify for coverage under private insurance or Medicare is also a common reason for reversals during United HealthCare audits.
  • Double Billing – Double-billing United HealthCare, Medicare, patients, and other payors can lead to payment reversals during audits; and, in some cases, it can lead to a referral to the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG).
  • Inadequate Patient Records – When conducting audits, United HealthCare examines whether providers have duly maintained all requisite patient records. If a provider cannot produce required patient records, this can lead to reversals regardless of whether payment was owed.
  • Illegible Patient Records – Failing to maintain legible patient records is another common reason for reversals during United HealthCare audits. If auditors cannot read the records in a provider’s file, they will assume that the records reflect non-compliance.
  • Telehealth and Telemedicine Billings – Telehealth and telemedicine services are subject to special rules and restrictions. Improper billings for these services are common; and, as a result, telehealth and telemedicine reversals are common as well.
  • Home Healthcare and Hospice Billings – Home healthcare and hospice services are subject to special rules and restrictions as well. If a provider does not take adequate steps to ensure strict billing compliance in these areas, this can also lead to reversals (and other penalties).
  • Consultation, Referral, and Discharge Billings – While providers can bill for consultations, referrals, and discharge services in appropriate cases, these are frequent sources of improper billings; and, as a result, they are typically focus areas during United HealthCare audits.
  • Inadequate Recordkeeping Procedures – Healthcare providers should follow documented recordkeeping procedures as part of their compliance programs, and they should be able to provide required documents to United HealthCare’s auditors upon request.
  • Inadequate Staff Training Procedures – Inadequate staff training is a common source of medical billing errors. However, inexperience and unfamiliarity with the relevant billing rules are not excuses for non-compliance.
  • False and Forged Records – Evidence that certifications, patient records, or other documents have been falsified or forged can lead to reversals, exclusion, and potentially a referral to the HHS OIG.
  • Upcoding – Upcoding involves billing for a service or item at a rate higher than the one prescribed by the applicable rate schedule or guidelines. While a common mistake, upcoding is grounds for reversal during a United HealthCare audit.
  • Unbundling – If a provider fails to bill for related services or items at their reduced “bundled” rate, this can also lead to reversals (and other penalties). Like all of the other billing violations on this list, this is true whether the unbundling is intentional or inadvertent.
  • Medicare Billing Violations – United HealthCare is one of several Medicare billing administrators working with the Centers for Medicare and Medicaid Services (CMS). When billing Medicare through United HealthCare, providers must strictly comply with the applicable rules, restrictions, and prohibitions.
  • Failure to Disclose – If a provider is unable or unwilling to provide billing or patient records during a United HealthCare audit, this will generally result in a presumption of non-compliance and reversal of payment for all associated billings.

While this list is extensive, it is also far from comprehensive. When conducting audits, United HealthCare looks for any and all grounds to reverse payments previously made. Auditors will usually examine providers’ pending payment requests as well. At Fortis, we take a proactive approach to managing our clients’ audits, using our in-depth medical billing knowledge and the insights gained from our extensive experience to help shield our clients from unnecessary consequences.

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FAQs: Managing Risk During a United HealthCare Medical Billing Audit

Why was My Practice Selected for a United HealthCare Audit?

United HealthCare audits all of its participating providers for medical billing compliance. As a result, if your practice has been selected for an audit, this doesn’t necessarily mean that United HealthCare has concerns about your practice’s billing history. However, facing an audit still presents significant risks, so an informed and proactive approach is required.

What Are the Potential Outcomes of a United HealthCare Audit?

United HealthCare audits have a few potential outcomes. One potential outcome is simply confirming that your practice’s medical billings are fully compliant. However, reversals due to alleged non-compliance are common; and, in the most severe cases, United HealthCare audits can lead to exclusion and referrals to CMS or the  HHS OIG for further inquiry.

How Do I Avoid Payment Reversals During a United HealthCare Audit?

Avoiding payment reversals during a United HealthCare audit requires clear documentation of compliance and a thorough understanding of United HealthCare’s auditing procedures. At Fortis, we have a proven track record of helping our clients effectively manage United HealthCare audits and avoid unwarranted reversals.

What Should I Do if I Know My Practice’s Billings Through United HealthCare Aren’t Fully Compliant?

If you are facing a United HealthCare audit and you are aware that your practice’s medical billings aren’t fully compliant, this is a concern that you will want to address proactively. Failing to affirmatively address known issues will be considered on par with intentionally submitting or covering up fraudulent billings. We have experience advising providers in this scenario, and we can help you make informed decisions about your next steps. But, it is important that you contact us promptly.

Do I Need to Engage a Consulting Firm for a United HealthCare Audit?

Engaging a consulting firm to assist with your practice’s United HealthCare audit is strongly recommended. These audits present substantial risks, and compliance on its own isn’t necessarily enough to avoid reversals and other penalties. Audited providers must be prepared to affirmatively demonstrate compliance and address issues that arise during the audit process. Flawed audit determinations are common, and a team of experienced medical billing consultants will be able to help you avoid unwarranted payment reversals and other unnecessary adverse consequences.

Speak with a Medical Billing Audit Consultant at Fortis for Free

If you are preparing to go through a United HealthCare medical billing audit, we encourage you to contact us for more information. We assist with United HealthCare audits nationwide. To speak with a senior medical billing consultant at Fortis for free, please call 866-808-4160 or tell us how we can reach you online today.

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