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	Pennsylvania Blue Shield Revises Audit Process

Healthcare Law Briefs

October 11, 2004

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PENNSYLVANIA BLUE SHIELD REVISES AUDIT PROCESS

In the August 2004 PRN, Highmark announced the revision of its audit process. The heading in the release refers to this as the "consultant review process", but this is the process by which Highmark audits your claims.

Heretofore, the process has been a three step process in which:

Highmark would retain an independent consultant to review your records and produce a report;
You would receive the report and would have the opportunity to submit additional information and request a review by a second consultant; and
You could then appeal any decision to the Medical Review Committee.

Highmark has eliminated the second step, and has justified this by stating that "this will allow for more timely conclusion to the review process".

This may be true, but I do not think time is the issue. The "second consultant step" was an important protection for providers. It allowed an "independent" consultant, although one regularly retained by Highmark, to review the issues considering both perspectives, i.e. Highmark's perspective and yours after you had the opportunity to review the files, provide additional information, and even provide an independent consultant opinion of your own. In cases in which the billing was appropriate, it has been my experience that this regularly allowed providers to resolve the matter without the need for a medical review committee hearing. Now, not only will the hearing be your only recourse, but the hearing will be performed by Highmark's selected medical review committee.

Furthermore, Although, the operation of this remains to be seen in the future, I do not yet know how this will impact your use of outside consultants. Will you be permitted to provide the outside consultant's opinion in writing or will your consultant be required to appear and testify? This submission of written affidavit/opinions is not permitted, this will make it much more difficult for you to present the opinions of outside experts.

If you have any questions on this topic, please contact Mike Cassidy at mcassidy@tuckerlaw.com.

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