Washington Post Examines Increased Health Insurer Audits of Physician Claims
The Washington Post on Monday looked at the "growing concern among private and government health insurers about the accuracy of physicians' claims and the system for calculating reimbursements." Both federal health programs and private-sector insurers increasingly have conducted audits of providers' bills to determine if providers are sufficiently documenting care, billing for unnecessary services or using correct codes for billing. Medicare is expected to audit 150,000 claims this fiscal year, compared with 128,000 and 6,000 audited in the two previous fiscal years, respectively. In the Washington, D.C., area, CareFirst BlueCross BlueShield last year conducted an audit of "tens of thousands of claims" from 2,800 physicians, "ignit[ing] a doctors' revolt," according to the Post. Physicians say such investigations are designed to pressure them to bill less for services to avoid increased scrutiny from insurers. Dr. Larry Miller, a Virginia-based allergist who has been audited by MAMSI, CareFirst and the state's Medicaid program, said the investigations are "just interfering with the practice of medicine. Just think if you were sitting in your office and you had examiners coming from every which way." However, insurance officials maintain that audits are necessary to avoid inaccurate claims that would drive premium increases, the Post reports. Former CMS Administrator Tom Scully said that Medicare's reimbursement system, in particular, is vulnerable to overbilling. "The fact is, when you create a system ... of price fixing, people are going to err toward the higher code if they can. ... When you set up one of these artificial kind of price-fixing mechanisms, you are incentivizing people" to use the system to their advantage, Scully said (Brubaker, Washington Post, 1/12).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.