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Retrospective audits must include parity discussion

January 11, 2016
by Julie Miller, Editor in Chief
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According to the Kansas Health Institute (KHI), insurer Blue Cross Blue Shield of Kansas is discontinuing the requirement for prior authorization of coverage for mental health services for its members. However, providers will still be expected to use good judgment on what is medically necessary.

Instead of coverage approval at the initiation of service, the plan will audit providers after services have been delivered. No doubt the practices will welcome a pass on all that administrative work surrounding prior authorizations, but for those who are audited, defending cases retrospectively will amount to even more work when all is said and done.

New Directions Behavioral Health, the plan’s carve-out administrator, will analyze data among providers to determine variations in care delivery. Outliers will need to provide documentation to show the treatment was appropriate. According to the KHI article, the insurer could require refunds of reimbursements if the care is not found to be medically necessary.

It’s easy for insurers to call into question cases that rack up high spending totals, leaving the onus on providers to document the rationale behind the care. But this is also an opportunity for providers to argue for parity. Hopefully any provider that is audited will have more than enough documentation to back up the services, while also making a point that most medical/surgical providers aren't audited in retrospect and instructed to return their reimbursements.

Keep an eye on Kansas. I wouldn't be surprised if a parity law suit emerges in time.


Julie Miller

Editor in Chief

Julie Miller


Julie Miller has more than 14 years of experience observing, analyzing and reporting on various...

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