MyHealthGuide Source: Mike Lanza, , Senior Vice President, USBenefi ts Insurance Services, LLC,
In our industry, there is much hesitancy to review in-network claims for billing errors and unnecessary treatment. One concern is that an audit will take too much time and may violate prompt pay rules, but that concern should not prevent a detailed audit process that could potentially save the Plan (i.e.,employer) significant claim costs. Prompt pay rules are in place for clean and uncomplicated claims. If a payer believes a claim audit is necessary to validate the payment because of the complicated nature of a claim, the claim is no longer a clean claim. The payer has the right and responsibility to request additional information from the provider to audit the claim.
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