NASW Shares Legal Issues in Health Insurance Audits

NASW National’s “Legal Issue of the Month” article discusses some of the issues involved in retrospective audits of mental health records. A retrospective audit occurs when a health insurer reviews past paid claims on a case by case or aggregate basis. Many provider agreements give health insurers the right to audit practitioners’ records. A retrospective audit is initiated by a letter from the health insurer or a third party acting on its behalf, usually requesting medical records from the practitioner in order to conduct an audit or review. When an audit notification is received, a social worker generally will have to determine whether it is necessary to comply with the record request based on the terms of the provider agreement.

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