Based on conversations with member hospitals and other hospital associations, there is an increasing number of health plans that are subcontracting with outside firms to do pre-payment audits of hospital claims. It appears the audits focus on high-dollar claims that may be subject to outlier payment or paid on a percent of charge basis. Hospitals report that some firms require an itemized billing for payment and will deny claims if not received within a specified timeline. It has also been reported some firms are requesting that hospitals change their coding of services under threat of denial of the entire service.
WSHA is concerned that such requirements and use of outside entities may circumvent laws regarding acceptance of clean claims and prompt payment and such entities may not provide a robust appeal and dispute resolution process. WSHA is considering possible discussions with the Office of the Insurance Commissioner on intervention but we need more specific information. If pre-payment audits are an issue for your facility, please provide detailed information to Andrew Busz at email@example.com or (206) 216-2533.