Current through Reg. 49, No. 38; September 20, 2024
(a) An insurance carrier may perform an audit
of a medical bill that has been submitted by a health care provider to the
insurance carrier for reimbursement. The insurance carrier may not audit a
medical bill upon which it has taken final action.
(b) If an insurance carrier decides to
conduct an audit of a medical bill, the insurance carrier shall:
(1) provide notice to the health care
provider no later than the 45th day after the date the insurance carrier
received the complete medical bill. For onsite audits, provide notice in
accordance with subsection (c) of this section;
(2) pay to the health care provider no later
than the 45th day after receipt of the health care provider's medical bill, for
the health care being audited:
(A) for a
workers' compensation health care network established under Insurance Code
Chapter 1305, 85 percent of the applicable contracted amount; or
(B) for services not provided under Insurance
Code Chapter 1305, 85 percent of:
(i) the
maximum allowable reimbursement amounts established under the applicable
Division fee guidelines;
(ii) the
contracted amount for services not addressed by Division fee guidelines;
or
(iii) the fair and reasonable
reimbursement in accordance with §
134.1 of
this title (relating to Medical Reimbursement) for services not addressed by
clause (i) or (ii) of this subparagraph;
(3) make a determination regarding the
relationship of the health care services provided for the compensable injury,
the extent of the injury, and the medical necessity of the services provided;
and
(4) complete the audit and pay,
reduce, or deny in accordance with §
133.240
of this chapter (relating to Medical Payments and Denials) no later than the
160th day after receipt of the complete medical bill.
(c) If the insurance carrier intends to
perform an onsite audit, the notice shall include the following information for
each medical bill that is subject to audit:
(1) employee's full name, address, and Social
Security number;
(2) date of
injury;
(3) date(s) of service for
which the audit is being performed;
(4) insurance carrier's name and
address;
(5) a proposed date and
time for the audit, subject to mutual agreement; and
(6) name and telephone number of the person
who will perform the onsite audit, has the authority to act on behalf of the
insurance carrier, and shall personally appear for the onsite audit at the
scheduled date and time.
(d) During the insurance carrier's onsite
audit, the health care provider shall:
(1)
make available to the insurance carrier: all notes, reports, test results,
narratives, and other documentation the health care provider has relating to
the billing(s) subject to audit; and
(2) designate one person with authority to:
negotiate a resolution, serve as the liaison between the health care provider
and the insurance carrier, and be available to the insurance carrier's
representative.
(e) On
the last day of the onsite audit, the health care provider's liaison and the
insurance carrier's representative shall meet for an exit interview. The
insurance carrier's representative shall present to the health care provider's
liaison a list of unresolved issues related to the health care provided and the
billed charges. The health care provider's liaison and the insurance carrier's
representative shall discuss and attempt to resolve the issues.
