What Are a Social Worker’s Obligations Under the New Jersey Administrative Code When an Insurance Company Demands to Conduct an Audit of Patient Records?
Health Care Insurance Carriers (“Carrier”) have specific, defined, and limited authority to have access to a licensed Social Worker’s records involving services paid through the Carrier’s Health Insurance Plan. Such access is not unlimited and sometimes an investigator on behalf of the Carrier will show up at the Social Worker’s office and demand to see the complete files identified by the investigator. Typically, such investigations are triggered by either complaints from patients regarding service or billing or a Carrier's suspicions of fraud based upon claims filed. Out of Network Providers, with a large patient base, are potential subjects of audits due to the volume of business and costs incurred by the carrier. It is not unheard of that a Carrier might use the opportunity of an audit to encourage a Provider to become an in-network Provider during the audit process.Read More