Reminder: Don’t resubmit claims involved in audits

Blue Cross Blue Shield of Michigan requests that you not resubmit inpatient, outpatient facility, professional or ancillary claims that are already part of an audit. Simply stated, don’t rebill to correct a mistake in billing or other errors, including ones involving a CPT procedure code, ICD-10-CM diagnosis, quantity or date of service.

Rebilling audited claims causes unnecessary disruptions for all parties. 

Once you receive a patient listing with an audit notice letter:

• Don’t adjust the related claims any further.
• Let your billing and finance departments know which claims we’re auditing.
• Ask your finance team to hold billing any more audit-related claims.

Audited claims could include cases for:

• Readmissions
• Diagnosis-related group
• Catastrophic-cost outliers
• Emergency room
• High-dollar claims
• Hospital physical therapy, occupational therapy and speech language pathology
• Ambulatory surgery facilities
• Freestanding outpatient physical therapy facilities
• Home health care

Audited claims could include the following types of providers:

• M.D.s, D.O.s and specialist physicians
• Certified registered nurse anesthetists
• Durable medical equipment, prosthetics and orthotics
• Home infusion therapy
• Independent physical therapy and occupational therapy
• Ophthalmology
• Oral surgery
• Pharmacy
• Podiatry
• Provider office infusion therapy
• Urgent care

For inpatient hospitalizations where the medical record doesn’t support the inpatient setting that was billed, hospitals can rebill Medicare Part B services from the denied hospitalization and be reimbursed. To learn more, see “We’re resuming Medicare Plus Blue PPO place-of-service audits” in the October 2019 Record

Provider audit suppliers conduct audits for readmissions to the same facility occurring up to 30 days from the date the patient was released from the hospital. Hospitals are responsible for all costs pertaining to readmissions denied under the Medicare Plus Blue℠ Readmissions Reimbursement Policy.

Hospitals can no longer rebill Medicare Part B services from the denied admission and can’t combine the admissions. To learn more, see “Blue Cross implements post-pay audits related to inpatient readmissions” in the January 2021 Record.