SIU stands for Special Investigation Unit, and nearly all insurance companies have one, especially health insurers. SIUs exist to investigate complaints of fraud, waste or abuse, and train claims personnel to recognize and flag suspicious claims. SIUs also have the authority to claw back payments and place providers on corrective action plans for persistent issues, as a condition of being a provider.
If a referral from claims staff or a third-party complaint result in an SIU audit, don’t panic and don’t ignore it. Instead, know what to expect and understand your options.
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What to Expect from an SIU Audit?
If you receive an SIU audit letter or a “records request,” contact an attorney right away. These requests are time sensitive. An attorney can help you determine the reason for the records request and advise you on your rights and options.
Generally, an SIU examining records from one patient is nothing to worry about, but an SIU asking for information about a cohort of patients could signal an audit – and potential liability.
Do not give the SIU more information than they ask for, and do not change or omit any records. Provide the records in whatever format the SIU requests and keep copies of everything you sent, along with a spreadsheet of all records submitted, the date of the submissions, and all communication with the SIU. Your attorney can help you manage this burden.
What to Do if the SIU Demands Recoupment?
If an SIU alleges fraud, waste, or abuse, it will move to recoup any money that was lost. Note the amount and the reason for the request.
Our firm typically advises clients to hire an attorney to negotiate larger sums (particularly those over $25,000). That said, if you disagree with the recoupment request and firmly believe the SIU made an error, you may want to engage an attorney to try and set the record straight. Once you are on the SIU’s radar, you may find your claims more frequently and carefully examined going forward, leaving your practice vulnerable to subsequent audits and recoupment demands.
If you choose to fight or negotiate the audit findings, review each claim included in the audit individually and create an argument to refute each finding (your lawyer can help). Do not hesitate to ask for an audit spreadsheet, so you can review the audit line-by-line. If the SIU did not base the amount it requested on the exact claims they audited (extrapolation), ask them how they up with the figure – and ask your attorney how you can contest it.
In your appeal, make sure to document any hardships the recoupment would cause your practice, as well as any financial difficulties you have had in the past. If you struggled financially during the COVID-19 pandemic, now is the time to note this (but only if your profits have gone down).
Again, keep a copy of everything you submit to the SIU. Should your audit be referred to law enforcement, you will likely have to compile and submit the records again.
What Are the Potential Consequences of an SIU Audit?
If audited by an SIU, you could face delays in payment from the insurance company, recoupment of previous payments, a corrective action plan, and even removal from the insurance plan.
The most severe action an SIU can take against you is to report you to law enforcement agencies like the Office of Inspector General (OIG) or the U.S. Department of Justice (DOJ).
Rarely, an SIU audit can lead to criminal charges. Frequently, it can jeopardize your practice.
Avoiding – and Surviving – an SIU Audit
Create and implement a compliance program to help you avoid errors and keep a copy of each claim you submit. Review your records regularly with internal audits, so if an SIU ever asks you for information, you will be ready to provide it.
Avoid these activities that may make you a target of an SIU audit:
- Not collecting copays and deductibles
- Failing to communicate about insurance claims with patients or authorized parties
- Code usage and claims patterns that stand out when compared to your peers’ data
- Not following the insurance company’s rules
- Letting patients know you do not follow the insurance company’s rules
- Upcoding, unbundling, and rebilling services (even by mistake)
- Revising medical records to hide mistakes (particularly after you have been notified of an audit)
- Billing work under the wrong doctor’s name
- Not documenting all communication with the insurance company
- Not understanding billing codes
- Falling behind on coding and documentation changes
- Adverse actions against a licensed provider by a State Medical Board; this will likely be reported to the National Practitioner Data Bank and may trigger an SIU audit
An SIU audit is serious, but it does not have to spell the end of your practice. Sometimes, an investigator simply wants to look at a single claim that doesn’t seem quite right. An attorney can evaluate the records request and help you respond in the best way possible.
