What Occurs When An HMO Accuses You Of Inaccurate Billing Practices?

Most physicians have contracts with HMOs to render health care to the members of those HMOs.  The contracts set forth, among other things, the approved billing practices of that HMO.  You, as the provider who is doing the billing, must know exactly what you can bill for and what supporting documentation you require in your records to ensure that you are paid for what you did.  It is not enough to take the position that you provide great medical care and you really do not have time to write down everything that the HMO says is necessary.  Some physicians have the idea that the HMO cannot tell them how to practice medicine and therefore whatever the doctor says he did  he should get paid for.

Unfortunately, this is a new world.  You MUST understand what information that you have to maintain so that your billing is accurate and cannot be challenged.  If you fail to properly, in writing, justify your billing you might end up on the end of a very sharp stick.  And, if you read your contract with the HMO, it probably says that you have waived your right to a trial on this issue and have instead agreed to submit the dispute to binding arbitration.

The following scenario is typical of the kind of problem you can get into with an HMO.  The HMO comes to your office and reviews the billing and medical records of perhaps 25 patients.  The reviewer finds that you have not followed the company’s billing procedures and/or that your medical records do not show that the treatment was necessary.  After this audit, the HMO sends you a letter with the results and tells you that you have over billed the HMO by, let us say, 25% on these 25 patients.  But that is not the really bad part of this situation.  What the next paragraph in the letter says is that the HMO assumes that you have over billed it on ALL of your billings going back 6 years.  They will then calculate that if you billed, for instance, $200,000 over the last 6 years, that you over billed on the entire amount and therefore you owe the HMO $50,000, that is, 25% of the amount.  And, if your contract has an arbitration clause you have waived your right to a trial by a jury on this issue and have instead agreed to submit the dispute to binding arbitration.

What can you do about this situation?  First, make sure you are documenting your billing so that you do not end up in this situation.  But, if you are faced with a large bill, you have to contest every entry to lower the amount that you owe.  There are ways to do this, but you will require some assistance to put your billing in the best possible light.

This informational blog post was brought to you by Paul E. Walker, an experienced NYC Physician Defense Lawyer.