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Provider Appeals
Hello,
We’re running into providers that are not providing any documentation during the audit process and when we send out the recovery letters they appeal and provide supporting documentation at that time. Does any SMA NOT allow that to happen? This is an unnecessary burden on our Legal Advisory Unit and creates unnecessary work for our PIU as well. Thank you!
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2 Replies
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When providers don’t submit documentation, we send a refund request letter or termination letter depending on the reason for the request. That gets their attention. Even if they do request an appeal, we at least get them talking and can withdraw the action before theappeal gets too far along.
Good luck!
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Two things — we have an administrative fine that we can apply (failure to have furnished the records to us upon request — the first time we requested they were due); and we have a provision in statute that precludes them from relying on documents in court that were requested and not furnished during the audit. Our statute (Florida Statutes) is mostly section 409.913 — the provision for sanction is all in subparagraph 15 (and then we have rules to administer those). The part that precludes the late-filed records in court is in subparagraph 22 of that section.
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