“Please Tell Me you Didn’t. . . How to Keep Clients Out of the Jailhouse, Poorhouse and Lawyers Out of the Nuthouse”
I just got off the phone with one of dozens of clients I represent from coast-to-coast (literally Temecula California to Raleigh, North Carolina), over what is called an “SIU recoupment insurance audit” which is part of a continuing war on doctors by insurance companies.
Although “SIU” stands for “Special Investigations Unit,” I like to call them “Spanish Inquisition Units,” because they blow in like the 1970’s Monte Python’s “Spanish Inquisition” television skit, demanding the production of documents relating to a small number of patients. There is no advanced notice and no time to prepare to produce the documents.
Because “nobody expects the Spanish Inquisition,” these SIU agents almost certainly will find fault in the documents which they then extrapolate across all the clinic’s claims. This lack of Due Process is designed to be patently unfair, calling to mind another famous quote, this time from a real-life cleric:
“If you give me six lines written by the hand of the most honest of men, I will find something in them which will hang him.
–Cardinal Richelieu, French Cleric and Statesman (1585–1642)
An SIU “recoupment audit” is a post-payment review of a certain number of patient charts (usually 29), to determine whether a service was “medically necessary.” Medical necessity doesn’t simply mean that the item or service was valid, but also that “necessity” is documented in the chart. If the chart is missing some required language, a signature, or receipt, or anything else is out of place, then the entire claim is deemed medically “unnecessary,” regardless of the patient’s need for the service.
These SIU auditors will then extrapolate the errors found in the 29 claims across the entire universe of a provider’s claims, which magically both puts money back in the pocket of the insurance company and give the patient the service for free. Due Process be damned.
In one of the worst examples, I received this week, with a provider had just received a $750,000 “claw back” demand from the SIU of a Medicaid HMO for payments for IV infusion drugs for poor patients with rare diseases. The audit found that documentation of receipt of the drugs by the patient was insufficient, some “box” wasn’t checked, even though the medical chart, the patient and the medical staff all agree that the patient received the drugs intravenously. You could line up the pope and a convent of nuns as witnesses, and it doesn’t matter to the SIU.
So I have to go in and try to win an appeal or arbitration award to reverse the finding of the SIU bureaucrats. Which sadly, brings me to my final literary reference:
The Oxford Dictionary defines “bureaucrat,” as “an official in a government department, in particular one perceived as being concerned with “procedural correctness” at the expense of people’s needs.