Humana, CareCentrix join audit free-for-all

Friday, June 12, 2015

YARMOUTH, Maine – HME providers and billing experts are reporting a recent spike in audits by insurance giant Humana and health plan manager CareCentrix. 

“I open the mail here for one reason,” said Robert Slama, CEO of Lakeland, Fla.-based Medi-Healthcare, who’s been audited by both companies. “I want to see the amount of recoupments going on.”

Why the sudden scrutiny?

“They got wind that they could get a lot of money back,” said billing consultant Sylvia Toscano, owner of Professional Medical Administrators.

While CareCentrix’s audits seem to be across-the-board, Humana’s seem to focus on claims tied to Medicare Advantage plans, Toscano says.

“CareCentrix is taking money back left and right for any reason under the sun,” she said. “Humana’s audits are relative to the Medicare Advantage plans. They want to make sure that Medicare guidelines are being followed.”

Humana and CareCentrix don’t appear to be targeting one specific product category, either, but Kelly Wolfe, president of Regency Billing and Consulting, says she’s seen a high volume of audits for L-codes, specifically off-the-shelf orthotics. 

“The L-codes are high-dollar items and they do have a history of fraud,” she said. “It’s always a red flag to me when providers are doing multiple L-codes on one patient and I think insurance companies look at it the same way.” 

While most providers have their ducks in a row, some might not be as thorough with private insurance documentation as they are with Medicare, Wolfe acknowledges.

“I think some providers feel safe when it’s private insurance and might not get all of the documentation in the progress notes and, of course, those providers are going to have possible recoupment,” she said.