What happens when a medical scheme conducts a forensic audit? Nirvana Nothnagel explains what practitioners need to know about audits, clawbacks, and their rights.
Transcript
[00:08][Eon] Welcome back to Legal Talk here on eRadio with Hahn & Hahn Attorneys, every Wednesday at ten o'clock in the morning, and then, obviously, the podcast afterwards. But right now, we're chatting to Nirvana today, and we asked you the question, "Have you ever been subjected to a medical scheme forensic audit or clawback?" And the majority said, thank goodness, said, "No." That was 75%. And then 17% said, "What is that?" And 8% said, "Yes." I am in the 17%. I said, "What is that?" Hopefully, Nirvana's going to help us understand that. Now, Nirvana, welcome back.
[00:54][Nirvana] Thank you, Eon. It's great to be back.
[00:57][Eon] Yeah, so, yeah, that's why we included that option on the poll. Because I'm sure not a lot of people know exactly what it is, but thank goodness we've got you here now. Can you give us an explanation? What exactly is a forensic audit in the context of medical schemes, and also, why are they conducted?
[01:17][Nirvana] So, in simple terms, a forensic audit is an investigation by a medical scheme, or, more often than not, by a third-party auditor appointed by the scheme. This audit will be into the billing practices of a healthcare provider. The stated purpose is to detect billing irregularities and to protect medical scheme funds, which ultimately come from member contributions. The legal basis for this power can be found in the Medical Schemes Act.
[01:45][Eon] Okay, okay, that makes sense. And then, what issues can arise during an audit?
[01:51][Nirvana] So, while audits are an important way to identify billing irregularities and protect scheme funds, difficulties may arise if the practitioner does not receive clear information about the concern, the records required, or the opportunity to respond.
[02:07][Eon] Okay, and what may a practitioner be asked to do during an audit? Can you tell us a bit more about that?
[02:13][Nirvana] Well, the practitioner is usually asked to provide patient records, billing information, and an explanation of the claim under review. The scheme or the auditor then assesses whether the claims comply with the applicable rules and codes.
[02:27][Eon] And what information should a practitioner receive about the amount claimed?
[02:34][Nirvana] Well, the practitioner should be given enough information to understand and respond to the finding, including the relevant claims data, methodology, and records. Some practitioners report that this information is incomplete or not provided at an early stage. Without it, assessing or challenging the amount can then be difficult.
[02:54][Eon] And what should a practitioner do if they receive a notice of a forensic audit, Nirvana?
[03:01][Nirvana] Well, the practitioner should review the notice promptly, preserve the relevant records, note any deadlines, and obtain appropriate advice before responding or signing any acknowledgement of debt or committing on email to anything to the auditors. Early advice can help clarify the issues and the available options.
[03:23][Eon] And just lastly, what kind of legal support can a practitioner expect?
[03:29][Nirvana] So, we assist the practitioners with their responses to the audit request while protecting the practitioners' rights, explain the basis of the audit, request the relevant information, and advise practitioners on representation and communication during the process. We check whether the practitioners have been informed of their case, given an opportunity to respond, provided reasons, and treated through an impartial process. We also assist with dispute resolution. So, if the matter cannot be resolved directly with the scheme, we then look at available options, which may include a formal dispute process, such as appeal to CMS, the Council for Medical Schemes, or litigation where appropriate.
[04:14][Eon] And that's Nirvana Nothnagel, Senior Associate Attorney at Hahn & Hahn, joining us today here on Legal Talk, keeping it short and sweet. Nirvana, thank you so much.
[04:25][Nirvana] It's only a pleasure. Thank you, Eon.