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?

By Eric Marcy |   Apr. 15, 2018

            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.

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Topics : Health Care, Record keeping, Risk Management, Audits, Professional Licensing, Insurance Company Investigations, Patient Privacy, Patient Records, Social Workers, Patient Confidentiality, Insurance Audits, Insurance Carriers, Insurance Carrier Investigations | 0 Comments Read More


By Eric Marcy |   Jan. 19, 2018

          Due to the nature of the practice a Psychologist’s obligations relating to the maintenance of proper records is unique.  A professional license takes years to acquire and faulty or erroneous record keeping may place one’s career and livelihood in jeopardy.  So too, the mishandling of an investigation or an audit may place may also jeopardize a lifetime of pride and work.  The consequences for failing to maintain proper records and mishandling an investigation or audit can be severe and may implicate administrative, civil, and even criminal consequences.

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Topics : Psychologists, Record keeping, Risk Management, Audits, HIPPA, Professional Licensing, Board of Psychological Examiners, Department of Banking and Insurance, Insurance Company Investigations, Patient Privacy | 0 Comments Read More

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