Auditors May Be Coming Your Way for Information Gathering

Your practice may have received a letter from United HealthCare about an upcoming HEDIS audit. You may receive such notices from other health plans as well, or from Medicare Advantage (MA) plans about a risk adjustment audit.

HEDIS - Healthcare Effectiveness Data and Information Set - is tool that more than 90 percent of America's health plans use to measure performance on important dimensions of care and service. These audits are for information gathering; auditors are not looking for errors or fraud and abuse.

Risk adjustment is the process by which the Centers for Medicare & Medicaid Services (CMS) pays Medicare Advantage plans, based on the health status of their members. MA plans submit diagnostic data from claims to CMS for risk adjustment calculation and payment. These plans also perform medical record reviews to identify additional conditions not captured through claims or encounter data and to verify the accuracy of coding.

Here are a couple of helpful tips:

  • Review your contracts and provider manuals for information regarding audit requirements. This will answer questions such as: Am I required to participate in the audit? Can I charge the insurance company for copies of the records? (Often the answer to the latter question is "no.")
  • Verify credentials of anyone claiming to be an auditor. Also, ask for documentation of the specific information the auditor wants to collect. If the auditor is legitimate, give him or her access only to medical records for the health plan that has authorized the audit.

Published Oct. 20, 2010

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Last Updated On

May 13, 2016