BC Advantage - 2021 Issue 2
The Year of the Audit: Stand Your Ground with Payers
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Article Overview
This article discusses heightened audit activity in 2021 across commercial and government payers, with emphasis on how providers and auditors can respond when audit findings appear unsupported. It focuses on documentation, auditor credibility, published policies, contracts, and other authoritative guidance that may be relevant in disputes involving medical necessity, rehabilitation, evaluation and management services, and telehealth-related review activity. The piece is aimed at compliance, coding, auditing, and revenue integrity professionals who need to understand audit risk and how to evaluate the strength of payer positions.
Why This Topic Matters
Audit disputes can turn on whether a payer’s review is supported by valid methods, documented authority, and consistent guidance. Understanding the kinds of audit issues discussed here can help compliance and coding teams assess risk, prepare for rebuttal, and identify when further documentation or escalation may be needed.
Article Sections
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Opening commentary on payer audits
Introduces the article’s perspective on audit activity and the general relationship between providers, auditors, and payers. It frames the discussion as an industry commentary rather than a payer-specific complaint.
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OIG audit dispute involving rehabilitation and hospitalization reviews
Summarizes a dispute involving federal audit activity, overpayment allegations, and questions about reviewer qualifications and audit methodology. The section also references broader compliance and legal process considerations.
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Commercial payer audit dispute involving E/M services
Describes a separate payer audit involving extrapolated damages, review methodology, internal credentialing, and the availability of binding guidance. The focus is on audit validity and the documentation supporting payer positions.
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Guidance for evaluating audit support
Offers broad advice on locating payer policies, contracts, utilization guidance, and other authoritative sources before or during an audit response. It also mentions the types of external guidance that may be relevant when internal payer documents are unavailable.
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2021 audit outlook
Closes with a general outlook on increased audit activity across multiple review programs and the impact of telehealth and COVID-19-era policy changes. It highlights the broader compliance environment for the year.
What You Will Learn
- What kinds of payer audit issues are being raised in 2021
- How audit methodology and reviewer qualifications can become dispute points
- Why published policies and contracts matter in audit responses
- Which broad sources of external guidance may be consulted when payer guidance is unclear
- How telehealth growth and pandemic-era policy changes may affect audit attention
Who Should Read This
- Medical coders
- Compliance officers
- Audit and recovery teams
- Revenue integrity professionals
- Physician practice administrators
- Health information management professionals
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