CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Post-payment audit, recovery, and adjustment procedures for commercial products

Governs BCBSRI's post-payment audit, recovery, recoupment, and provider/institution rights and timeframes for commercial (non-federal) products in accordance with Rhode Island law; affects healthcare providers and institutions contracting with BCBSRI.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyPost-payment audit, recovery, and adjustment procedures for commercial products

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 2022

Next Review DateN/A

Key ActionUpon request and at no cost, providers must provide billing, financial, and medical records (electronic copy or remote access) within 30 calendar days.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18 monthsstandard audit/recoupment period

12 monthsmental health/substance use period

30 daysrecord production deadline

Commercial onlyapplies to

Post-payment Audit and Recovery Criteria

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Post-payment audit and recovery criteria

Procedural criteria and limitations for post-payment audits and recovery:

BCBSRI may perform post-payment reviews, audits, or investigations of paid claims that may result in recoupment or set-off of funds.

ALL of the following

Statutory timeframes for recoupment from providers
- Recoupment or set-off for most providers must be completed no later than 18 months after the date the completed claims were initially paid (RIGL).
- For claims submitted by licensed mental health and/or substance use disorder providers, the recoupment period is 12 months.
Institutions/hospitals: Review or audit of an institution or hospital shall be completed in accordance with the time set forth in the provider contract, or if no contractual timeframe exists, the statutory timeframes apply (see above).

ALL of the following

BCBSRI may elect to extrapolate audit results to a defined audit population using generally accepted statistical sampling principles and recognized probability techniques.
Extrapolation is limited to the defined audit population and product area; results from one claim area or product may not be carried over to other areas or products.

ALL of the following

Upon request and at no cost to BCBSRI, the provider must furnish billing, financial, and complete medical records relating to audited claims.
BCBSRI and/or its audit designee will be provided an electronic copy of the complete medical record or granted remote access to obtain records for each audited claim within 30 calendar days following request.

ALL of the following

Failure to provide access to medical records as requested will result in recovery of the full claim amount.

ALL of the following

Exceptions and limitations
- The statutory timeframes do not restrict review, audit, or investigation of claims submitted fraudulently, claims that are or should have been known to be part of a pattern of inappropriate billing, coordination of benefits issues, duplicate claims, or claims subject to federal law permitting longer review periods.
- Providers may voluntarily correct underpayments or overpayments outside these timeframes; BCBSRI may voluntarily correct underpayments outside the statutory timeframes.

ALL of the following

If a claim was denied or no payment was made, contractual timely filing and appeal deadlines applicable to the original filing apply for requests for adjustment or appeal.

Coding Applicability and Timelines

Coding applicabilitymixed

No codes listed

Record production timeline — provider obligations

Deadline to produce recordsProviders must provide an electronic copy of the complete medical record or grant remote access within 30 calendar days of BCBSRI's request.

Cost to BCBSRIRecords must be provided at no cost to BCBSRI or its audit designee.

Scope of recordsIncludes providers' billing, financial, and medical records relating to covered health services for the audited claims.

Format optionsElectronic copy or remote access for each audited claim must be provided.

Provider Responsibilities and Audit Consequences

Documentation Required

Provide billing, financial, and medical records on request (30-day deadline)

Upon request and at no cost to BCBSRI, providers must provide BCBSRI and/or its audit designee with providers' billing, financial, and medical records relating to covered health services; BCBSRI and/or its audit designee will be provided an electronic copy of the complete medical record or granted access to obtain records via remote access for each audited claim within 30 calendar days following request.

Records include billing, financial, and medical records related to the covered services.
BCBSRI or its designee must be given an electronic copy of the complete medical record or remote access.
Provider must deliver records within 30 calendar days of the request.

Denial Risk

Failure to produce records may trigger full claim recovery

If a provider fails to provide access to medical records as requested, BCBSRI will recover the full claim amount.

Prior Authorization

BCBSRI may extrapolate audit results to the defined audit population

BCBSRI may elect to extrapolate audit findings to the defined audit population using generally accepted statistical sampling principles and recognized probability techniques; extrapolation is limited to the defined audit population and may not be carried over to other areas or products.

Extrapolation sample shall be derived using generally accepted statistical sampling principles and recognized probability techniques.
Defined audit population means the area within a specific BCBSRI product (e.g., emergency department claims for the BCBSRI commercial product).
Extrapolation from one claim area or product may not be applied to other areas or BCBSRI products.

Key Definitions

Healthcare provider — definition

DefinitionAn individual clinician (independently or in a group) or any healthcare facility, including mental health and/or substance abuse treatment physicians or other licensed practitioners identified as primarily responsible for care.

IncludesPhysicians and other licensed practitioners providing mental health and substance abuse treatment.

Applies toNon-institutional providers and institutional facilities as defined under RIGL and this policy.

Defined audit population

DefinitionThe area within a specific BCBSRI product (e.g., emergency department claims for the BCBSRI commercial product) to which extrapolated audit results apply.

LimitationExtrapolation of audit results for one claim area or product may not be carried over to other areas or BCBSRI products.

ApplicationUsed when BCBSRI elects to extrapolate audit findings using generally accepted statistical sampling methods.