Agent Agent Agent Agent
Employer Employer Employer Employer
Provider Provider Provider Provider
Home Contact Provider Customer Service Site Map Search
Regence Blue Cross Blue Shield of Oregon
Oregon state health insurance For Physicians, Other Health Care Professionals and Facilities
BlueCard Program »
Care Management »
Claims & Billing
Contact Us »
Contracts/Credentialing »
Cost & Quality »
Educational Tools »
Health Care Reform »
Products »
Secured Site
Provider Center »
Provider Search »
Provider Library »
RegenceRx Pharmacy »
TriWest »
Wellero »
Claims and Billing - For Providers  - Receiving Payment
Provider Audits

We audit the billing of our participating physicians, dentists, other health care professionals and facilities. While many of our audits are to determine whether we have been appropriately billed, we also audit to determine:

  • Medical necessity
  • Proper utilization
  • Coverage of services
  • Appropriateness of services
  • Accuracy of claims submitted

Audits are also done in the case of abusive billing practices or to determine the possibility of fraud. Trained auditors review all areas of medical services, including:

  • Hospitals
  • Physicians
  • Pharmacies
  • Practitioners
  • Laboratories
  • Ancillary health care providers
  • Suppliers of durable medical equipment and supplies

All audits comply with the laws, statutes and regulations pertaining to the confidentiality of member records. Information is not disclosed, except to accomplish the audit or report findings/conclusions where appropriate and necessary.

Audits are conducted in the offices of our providers and occur at a mutually agreed date and time within the timeframe specified in your agreement with us.

In the event of an audit, please allow sufficient space within your office to review records and copy those records relevant to the scope of the audit. The audit may include charges to members not covered by agreements with us. However, the provider may obscure or remove these names from the billing records being audited.

Copies of relevant records may be removed from your office for the purpose of comparison with claims that have been submitted to us. Our staff will conduct this review at our offices. We will protect the confidential nature of the member records. We will destroy all copies of documentation acquired from an external audit review in a manner that will protect the integrity of confidential information and abide by all laws, statutes and regulatory requirements concerning the protection of confidential medical health care information once the audit file is closed and the need to retain any such information no longer exists. The Health Plan, as a responsible health care services contractor, is obligated to ensure the integrity of claims submittal and its reimbursement system. Therefore, it is our policy to exercise our contractual ability to audit documentation in support of claims submitted on behalf of our members.

Additional audit provision information is available in your Health Plan agreement.


Back to top

What you should know about Post-Payment Audits
Our Payment Integrity department is dedicated to ensuring that claims have been paid correctly by performing post-payment audits. Overpaying or underpaying for services rendered is a disservice to both our providers and our members.

Audit tips

Follow instructions in the request letter
Submit the requested information electronically
Submit all information prior to the due date indicated

Upcoming audits

High Dollar Audit

We are responsible for performing reviews of all claims over $250,000 that meet certain criteria as stipulated by the provider/facility contract. The High Dollar Audit is designed to verify the accuracy of the line item charges submitted for payment in a provider’s itemized bill as indicated by the medical record.

This review is not based on the medical necessity of the services provided or the accuracy of the coding. It may be performed both pre-payment or post- payment.

Records are requested for all claims reviewed under the High Dollar Audit process. The records we need to conduct our audit are identified in the request that we send to each provider. If the requested records are not provided within the time span identified in the letter, the entire claim may be denied.

Once we have completed our audit, the provider will be notified of our findings in writing and both overpayments and underpayments will be delineated in an Audit Detail worksheet sent with our Finding Letter. If the provider does not agree with the determination, appeal rights are also delineated within the Finding Letter.

Skilled Nursing Facility audit

Our upcoming Skilled Nursing Facility (SNF) audit will retrospectively review SNF claims to:

  • Assess compliance with Minimum Data Set (MDS) assessment requirements
  • Validate accuracy of Resource Utilization Group (RUG) coding
  • Ensure utilization of services in accordance with CMS guidelines.

At this time, this audit only applies to Medicare Advantage claims. An audit of commercial claims will be performed later this year.

Please note:

  • It is the fundamental responsibility of every provider to bill and code accurately. This review will be applied to the complete span of care (from admission to discharge comprises one span of care).
  • The Resident Assessment Instrument (RAI) manual governs submission of MDS assessments for SNF patients.
  • This is a review of the services provided as defined in Chapter 8 of the Medicare Benefit Policy Manual. There is no member liability.

Ventral Hernia Repair Code Pairs
The purpose of this audit is to determine if support exists for CPT codes 49560, 49561, 49565, and 49566 to be billed with CPT codes 15734 and 15734 with a Modifier -59.

  • Main codes: CPT 49560, 49561, 49565, and 49566
  • Denied code: CPT 15734, 15734-59

Please note: If we request records be submitted from your office, please submit them within the 45 day timeframe noted on the letter received.

Lap Hernia Repair Code Pairs
The purpose of this audit is to determine if support exists for CPT codes 43281 and 43282 to be billed with CPT codes 43279, 43280, 43644, 43645, 43770, 43771, 43773 and 43775.

  • Main codes: CPT 43279, 43280, 43644, 43645, 43770, 43771, 43773, and 43775
  • Denied codes: CPT 43281, 43282

Please note: If we request records be submitted from your office, please submit them within the 45 day timeframe noted on the letter received.

Payment integrity audit process timeframe requirements
As part of our ongoing payment integrity audit process, we inform our providers of any upcoming audit activities requiring medical records that may impact them. Here are our expectations of submission of medical records for audits. There are no exceptions to the following policies, unless otherwise required by law:

Providers have 60 days to submit records. 
We will initiate a Technical Denial recoupment for the claim or the item(s) within the claim that is (are) under review on day 61 for providers who have not submitted all of the requested records by day 60.
Records received from providers after a Technical Denial recoupment has been initiated by us will be reviewed in the order received and no later than 30 days after receipt.
Providers may submit records post Technical Denial recoupment within 18 months after payment of the claim or notice that the claim was denied (Note: Hospitals have different time frames. Refer to contract terms for specific timeframe.)
Records received after the timeframes indicated above will not be reviewed. The postmark date, the fax date or email date on the provider's submission will be deemed the date of receipt.
In the event that records are received by the Health Plan after the dates indicated above, we will notify the provider that the records were late and that no review or adjustment will be made.

Refundable situations
While findings will be different for each audit depending on audit area, contract language and our policy, the following are considered refundable to us in the absence of specific language in the provider or facility agreement to the contrary. There are no exceptions to this, unless otherwise required by law:

Items not listed within the operative report or documented in the medical record
Items for which there is no physician's order (even if documented in the medical record)
Notification from the provider that he or she has no records for date of service; all charges will be removed

 

Back to top

 

 

Note: To print a PDF document, you need Adobe® Reader®. Download it now for free