7 - Responding to an SIU Audit as an ABA Business: My Story

Full Disclaimer: This is not legal advice.

Help! I've received an SIU Audit!

So you have been audited. Don’t necessarily panic, but be vigilant - if this is an Investigative Audit (SIU), and not a “quality monitoring” review, then they are likely seeking recoupment.

What’s the difference? Every insurance company uses a different name for their audits. An Investigative Audit is one that will result in recoupment or criminal charges if they see fit. They're looking for what the define as waste, abuse, or fraud. While it may seem obvious to you that you did not commit waste, abuse or fraud, the way that some insurance companies define and twist the meanings of these words will have you fighting for your company.

A Quality Monitoring Review (there are other names for other companies) is basically a review of your data, intake docs, plans, assessments, notes, etc to make sure that you are in-compliance. These will issue you a “grade” based on some sort of monitoring tool. These are designed to keep you compliant, but they often times fall short of that goal (more on that later)

You are likely not here to talk about a quality monitoring review - you're here for the scary one, the SIU audit. I'm here to help.

Understand That This is an Maneuver to Claw Back Money

In March of 2023, I received a fax from one of the medicaid MCOs in my area: a medical records request conducted by a special investigator. My heart sank into my chest, and the color drained from my face.

There it was in it's glory. The table included 60 sessions across 3 different clients. They wanted everything: all medical records or documentation to support the codes that we billed. Every session note, every intake document, every treatment plan, everything. And we have 30 days to get them submitted. Wow. What an undertaking.

I immediately jumped into action to get everything together. They said everything.

1. Intake documents (procedures, rights, intake packet, CDE, etc.)

2. Initial assessment (raw data, indirect assessment tools, actual report)

3. Daily session notes for 97153

4. Supervision notes for 97155

5. Group notes for 97158

6. Parent training notes for 97156

7. Subsequent treatment plans and reports

8. List of every provider who worked at your facility during that time (this also includes your techs - apparently- and you must provide their registration numbers if your state has them, as well as proof [certificates] of registration).

I started getting it all together and realized that it was an immense amount of paperwork. I decided to contact the auditor. It's still day 1. I asked her if I could email it or put it on a flash drive instead of killing a billion trees needlessly. She said that I could mail a flash-drive.

I hyper organized everything. Folders and subfolders. Everything organized by client, by code, in chronological order. It was a painstaking process, but I thought that if I obviously put forth effort to make their lives easier, that would count for something.

On the 4th day of scanning, copying, organizing, downloading, converting, etc., a second fax arrived from a different MCO. Dear ABA Facility: The Special Investigations Unit (SIU) is conducting an assessment of services rendered...

There was nothing random about it. There was coordination between the two companies. The second audit requested over 100 sessions across 3 more clients. The deadline was just days after the first one.

Understand this, if you receive an SIU audit from one company, then you will likely receive another one from someone else. They do communicate. Whatever irregularities they think they found, it is not kept a secret. And although insurance companies frame these investigations as an attempt to verify if services were billed appropriately, it is sometimes a means to clawback money.

What is a clawback? SIU clawbacks and offsets refer to the recovery of previously paid claims or the reduction of future payments by insurance companies. These actions are typically initiated due to perceived instances of fraud, waste, abuse, or contractual discrepancies. The keyword here is "perceived" as you likely do not believe that you've committed fraud, waste or abuse but their perception is that you did.

Why me? There are a few reasons that you were "identified" or targeted. I straight up asked one, and they said that there were irregularities with how I billed. Meaning: I was an outlier. They are using data, just like we do, to determine if someone is possibly committing fraud, waste or abuse. If you show up as an outlier on a graph, they are going to investigate. Other reasons? A parent, worker, or someone close to your organization reported you anonymously.

What do we do? Some resources out there say lawyer up as soon as you get an SIU audit. Lawyers can be expensive. Maybe I won't need one; maybe after the insurance company reviews my paperwork, they will approve everything and we can move on. That's basically what I believed.

A Quick Timeline of Events

I submitted everything 2 weeks early. I included a cover letter explaining some of the quirks of my notes. I asked that after the audit was completed that they give me pointers on how I can improve my documentation. I put everything into a neat manilla folder and mailed it with next-day delivery. I emailed my auditors that the paperwork was headed their way via USB and cover letter. The next day, they informed me that they'd received the items.

And then I did not hear from them for 6 months.

It was October and the fear of the audit had almost completely worn off - I had almost forgotten that it even happened. The ignorance was absolute bliss. But I could still feel the fear of not knowing, quietly gnawing away. I emailed one of the auditors and asked if there were any issues, as it had been 6 months since submission and no one had contacted me.

She responded quickly, apologizing but stating that she was not working on my case and someone else had taken it over. She CC'ed that individual on the email. That person did not contact me. After 2 days, I reached out to them again. She later responded saying that I would receive everything at the end of the week once she got approval. I thought that was extremely strange at the time - it's been six months without a word from you guys, and now, the week that I randomly contact you, everything is ready?

Except it wasn't ready. I did not hear from that individual for nearly two weeks. And then one night, as I was bathing my 2 year old, I received an email from her with the results of the audit.

The PDF started: In an effort to combat fraud, waste, and abuse (FWA) the Special Investigations Unit (SIU) conducted an assessment of your recently supplied medical records for some of our member(s) and/or their dependents. Our review identified a 100% error rate for the following issues... Based on the Results, we identified an overpayment of $XX,XXX.XX and are required to recover the overpayment from you.

I emailed her and said that there had to be a mistake. I admit, my email was full of emotion and anger because there was no way this was accurate. I pride myself on providing a high level of care to my clients. Everything we do is ethically sound. And this insurance company is telling me that not only are my documents 100% in error, but they've deemed my services waste / fraud / or abuse, and they wanted all of those sessions paid back. I went back to the original email and read it front to back, over and over and over again.

Items that were100% in error (according to them):

1. Start and stop time for each session.

2. Narrative of what happened in the session: Describe what programs/ interventions were run during the session. Describe each attendees’ responses to interventions through the session; and Describe each attendees’ barriers to progress).

3. Documentation of correct billing code to be used.

4. The Name, signature, and credentials of person(s) delivering the services

1. What? Every single one of my session notes has a start and end time. I can refute that easily.

2. Narrative of what happened? Since when do techs need to write narrative notes? I wonder what they mean by this. My BCBAs write in depth narrative notes for supervisions (97155).. I provided so many pages of notes describing responses to interventions and barriers to progress. I don't understand.

3. What does this even mean? Documentation of the correct billing code? Of course I've documented the correct billing code. Did they want the billing code on the session note for techs? My techs and parents don't even know what these billing codes are.

4. My staff always sign their names; I know for a fact I am not 100% in error.

It wasn't more than 48 hours after receiving the results of the first audit before the second audit results came in. Same story: 100% in error. 5 digit recoupment amount, three times as large as the previous one. The coordination of the results occurring a day or two apart had me feeling sick. For several days, I did not sleep or eat or smile or laugh. The amount of money between the two audits would cripple my small business. It was more than my annual salary. I could possibly get a loan, but I'd be paying it off for years. And for what? I did these services. How can an insurance company do this? How can they get away with this?

I needed to shake off the shock. I needed to respond. I told both auditors that I requested a phone call to discuss the results. The first one scheduled a call with me the next day. The second one would not speak on the phone, and instead, insisted on a video call with the entire audit team. I scheduled it without giving it another thought.

My phone call was the next day. The auditor was kind and patient, explaining the results to me and asking what my concerns were. I explained that I felt most of these findings were in error, that they were insulting and I didn't agree with them. I also noted that when I added up the amount due to them in the spreadsheet, it was $5000 less that what she said I was owed on the cover letter. She admitted to that mistake. I then said if I can't trust you you to have correct amount owed, how I can I trust you with the results of this audit. Had I not attempted to refute this thing, I would have paid $5000 more than I was even supposed to.

I told her I would like to refute the findings. She explained their process for refutation:

If you disagree with our findings, we must receive a written notification of rebuttal within 30 days. Documentation should, at a minimum, include the specific claims in question, the reasons you dispute the findings and documentation to support your position

At first, I thought this meant I had 30 days to tell them I wanted to refute the findings. She clarified that I had 30 days to submit everything. She gave me a due date via email. I later learned from a different MCO (yes, I was audited again 1 day after receiving the findings from the 2nd audit - coordinated attack) that I actually had 30 business days, which are very different than 30 normal days. The communication and clarity on their end was incredibly poor. And this became a motif for my entire SIU audit experience.

Shake Off the Initial Shock and Get Into Attack Mode

I got off that call extremely pissed off. I decided that I was going to become an overnight expert on SIU audits, and I was going to respond with an all out offensive.

While waiting for the 2nd insurance company to schedule my video call, a 3rd medicaid MCO audited me, mirroring exactly what the previous 2 did. It happened 1 day after receiving the 2nd audit. At this point, I was numb. The shock was gone and I needed to get aggressive.

As I waited for my video call with the second insurance to be scheduled, I began to read every piece of correspondence from both audits. Here's a list of items that they will give you:

1. Cover letter generally explaining whats wrong, how much you owe, who to contact, and how much time you have to get these things done. They usually give you 2 options: write them a check or make a formal rebuttal. You've basically got 30 days for both.

2. A spreadsheet broken down by claim, date, client, and error. The "errors" seem to be copy and pasted from some sort of memo or rule book for the auditors as it's the same thing over and over again.

3. Another letter with a corrective plan of action. They're not only labeling you guilty and charging you with a recoupment, but also giving you a plan of action to correct your mistakes.

From these materials, I learned what "rubric" per-say that they were using to make all of these judgements: the Louisiana Department of Health ABA Provider Manual. They listed other items as well, such as:

• LDH Specialized Behavioral Health Fee Schedules

• [Insurance Company Name] Provider Manual

• [Insurance Company Name] Special Investigations Unit Fraud, Waste and Abuse Procedures Manual

• CVS Health HealthCare Anti-Fraud Plan

Up until this point, a had very little contact with any of these manuals. I've been in operation for 5 years, and while the ABA Provider Manual had been referenced by some provider reps, it was never spoken of as an end-all-be-all bible for ABA services.

Guess what? It is the Bible. It is literally the only thing that matters. They hang on every - single - specific word or interpretation of that living document.

I decided to turn my attention to the manual and memorize it. A friend who is an attorney said to use their language against them. I read the manual front to back - it was only 36 pages. Do you know how many pages were dedicated to explaining the requirements for a session note?

ONE PAGE. NINETY EIGHT WORDS. Here it is in all it's glory:

I went back and read the correspondence again. In both audits, 3d was omitted, but 3a - 3c were included as violations. That was convenient of them - all 97153 services are completed by an RLT and that would eliminate the need for 3a - 3c. Plus, when reading the documentation requirements, I was under the impression that 3a - 3c was referring to what a BCBA should be doing during 97155, not what a tech should be doing during 97153.

Other key takeaways:

1. Name of session attendees: are you referring to the client? Or do techs also count as attendees? And what happens if a BCBA supervises that session (97155), are they now an attendee? What if the parent is observing and 97156 is being run concurrently? What if we are in a group (97158) - do you require the names of the other clients in that group? This requirement is so vague and general that it leaves a lot of room for interpretation.

2. Start and stop time for each session: what are you defining as a session? My definition of a session is when the client arrives and when the client leaves. But again, this is up for interpretation - is it a new session if more than 1 tech works with that client in the same day (i.e. does each tech need a start and end time?). What if group is run in the middle of the day, and 2 techs work with that client at separate times - are you implying that this is 3 separate sessions and not one? Does each tech change represent a new session? Does each code changes represent a new session? Is it possible that one day of therapy is really upwards of 6-8 sessions and each requires a note? This requirement is also extremely vague with no specifications made to a code or if multiple providers work with a client.

3. Narrative of what happened during the session: while this one provides some specifics (i.e.programs / interventions, responses, barriers), it does not explain which code it is referring to or what a narrative is. How long does the narrative need to be? Can it be bullet pointed or provided from a list of items? Programs and interventions are including in our data, do I need to write a paragraph about them any way? It would seem that the first 3 bullet points are referring to a 97155 / 97158 note and nothing else, as 97153 is a direct code and not bundled. And with the last bullet, it nullifies the first 3 bullet points - so does that just apply to 97153?

4. Documentation of correct billing code used: I'm assuming that this means that the billing code needs to be included on the note, but it's really not explicitly stated as to what this means. Is this referring to a daily log to track the correct billing code used, or does that code need to be on every data sheet?

5. Name, signature, and credentials of person delivering service: this one seems obvious enough. The only issue is if the person does not have credentials. In Louisiana RLT is a registration and not a credential - it is not the same thing as an RBT. RLT is basically a title, like para-professional or tech. So all techs need to put RLT after their name? Do we also need to put degrees? What about parents - do they need to sign?

6. All documentation must be legible, easy to read, and individualized to each client: If a signature is not legible, you cannot be held at fault according to the NNA. In addition, legibility of a document is highly subjective, and thus, this line is quite problematic.
   

But that's it, that's all we have to go off of. I also wanted to note that they call the documentation a daily log or daily documentation. The semantics are important. They're using semantics against me in this audit, so I will use them right back.

Log as defined by Webster: a record of performance, events, or day-to-day activities.

When I think of a log, I think of tables or spreadsheets. Data entered into a record. This is very different than a narrative note and seemingly contradicts it. At the same time, the LDH Manual says: Daily Documentation / Log. So it implies that either one is fine, when in fact, it's possible that both are required (not one or the other). This is important to my specific audit because I did not submit any of my "daily billing logs" in the initial audit request. It seemed like a redundancy. My logs contain the date, time, code, units, and provider for all services provided that day for each client. I typically use it to prepare me for billing and as a checks / balances system.

The reason that this is important is because all of my 97153 data sheets from 2020 - 2022 did not contain the code on the data-sheet specifically, though the title of the data sheets were "Daily Session Note" or "Session Note." If I had turned in my Daily Logs, would I have been forgiven for not having the code on the session note, since it was on the log? That was a question for later. I needed to continue to find cracks in their armor and attack.

1) They said that my treatment plans were not signed and dated. Of the 20+ treatment plans that I submitted during the audit process, 3 were not signed. I had actually explained why they were not signed during the original submission: in 2020 and 2021, the signed original copies were given to the parents, so I did not have a signed copy on file. After 2021, all treatment plans were signed on the last page and dated on the first page. I used the manual to my defense, as it does not say where the signature or date need to be. This was a crucial defense, as the first auditor voided ALL of my 97155 notes because of apparent missing signatures /dates on our treatment plans. You can start to see that there was an absolute goal to get our documentation to be 100% in error. I truly believe that there is some sort of incentivized system in place to hit these thresholds.

2) They said that the CPT code was not on the service notes. This was mostly true in my case, as 97153 was not on any of my direct session notes. However, they did not make it clear that a Daily Log could also be provided. And after dissecting their LDH Manual, I was going to use that against them. I had a Daily Log for every client, every day, with every single code billed and I would be providing it with my rebuttal.

3) They said that my session notes were too brief and not complex enough, lacking the narration that the LDH required. Specifically they said: documentation does not support units billed: Session narrative and trials sets lacked the complexity and/or volume of detail to justify the service duration documented in the progress note and billed on the claim in 174 claims (95%). In these cases, the documentation was either too brief and/or simplistic in content and the length of service claimed (and therefore number of units billed) was not supported. Most often, these notes do not provide the narrative components required for the daily notes (e.g., lacks discussion of challenging behaviors, setting events, staff intervention, member’s response to intervention, or no discussion of progress) or the number of behavior trials completed was not included. Per LDH ABA Provider Manual Section 4.4: “The daily documentation/log shall include a narrative of what happened in the session including: what programs/ interventions were run during the session; attendees’ responses to interventions through the session; and barriers to progress. Daily documentation/log will serve as a way of communicating important aspects of the treatment session with the next tech or provider” p 3-4.

This one was going to be tricky to combat. It was true: my 97153 notes were not written in a narrative format. Having done ABA in some form since 2009, no agency that I worked for had ever required techs to take narrative / paragraph styled notes. I was honestly not aware that it was even a requirement until learning about the specifics within the LDH Manual. How could I fight this one when I was technically in violation? The first thing that stuck out to me was section 3d from the manual: if an RLT delivers services, recorded data is sufficient, and a narrative is not required. But there was a problem: this specific line was not added to the manual until July of 2023 (2 months after my audit started).

This was good and bad for my case. My audit did not officially end until October. Meaning that the changes to the manual occurred during the audit and not after, as a technicality. Second, the changes made to the manual supported my biggest reasons for not having narrative notes for my 97153 codes:

1. It violates the CPT 97153 code as it was designed

2. The perceived simplicity of my notes is subjective

4) They said that my service notes lacked signatures. This was partially true and was something that I was unaware of prior to these audits. Our software experienced a glitch when we first started using it when we first switched from paper to digital. One of the main glitches was that when signing the note to close out a session, the session note would freeze and restart. An apparent work-around was to sign extremely quickly to get to the next window. Staff took it upon themselves to mark an X. There were dozens of documents in which techs signed just an X for their name. This could be an issue. But I had a solution or at least an idea. During the review, I would gather signatures from my staff and attest that they did sign those X signatures. I would also provide payroll times in and out to corroborate that they worked on those days during those hours. It wasn't perfect, but it had to help my case.

5) They said that we billed the wrong number of units for 10% of the sessions. I looked at each note, compared the start and stop times, and looked at the units billed. They were all correct. Every single one. When digging further, I could see the issue. The auditors didn't understand concurrent billing (when we billed 97155) or they confused start / stop times when 97158 was billed on the same day. This was an easy argument for me.

6) They said that my staff members lacked proper credentials for completing / signing off on the services. All of my BCBAs list their credentials when signing, however my techs did not. They were listed as "Technician" on the document, which later when I called Manager of ABA for Medicaid, she told me that Technician was sufficient. In some cases, it just said "Therapist." What was extremely frustrating was that I gave the insurance company the registration certificates of all of my staff, and the licenses of all of the BCBAs. My whole staff is and was properly credentialed - I am definitely fighting this. I also noted that Louisiana refers to Registered Line Technicians as a registration - not as a license. Having learned that it was required, all future notes included this "credential" but prior to the audit, I did not have that info included on most 97153 notes.

Those were the most damning ones. Those were the ones that they said 90% or more of my documentation was missing. And in my opinion, they were mostly wrong. I can fight this.

The Video Call Conference

The days leading up to the video call, they asked me to give them a list of my own grievances. I typed up a quick 3 page synopsis of each area I wanted to cover and emailed it to them. With the amount of time between that email and the actual video conference, I did not want to arm them with too much information - they could research or formulate their own arguments against me during the video conference, and I needed to have some sort of upper hand after getting my legs cut out from under me. This was my one shot to get on the offensive.

This may seem like a weird thing to say in the middle of an SIU audit, with your business and financial well being on the line, but I realized it a couple of days before my scheduled video call with the 2nd insurance company: I needed to show them that I was a human being. They've been looking at our company through a microscopic lens, and we were just a case number to them. They were doing their job diligently, but at the end of the day we were just a case number or a company name on a piece of paper.

I began working on a powerpoint to present to them during our video call. I included pictures of me, my wife and 2 year old, my clinic, my staff, and our agency at local autism events. I wrote a short speech about my journey as a BCBA and my roots in the state of Louisiana. I talked about the lives we changed, the families who relied upon us, and the community that I dedicated my life to nearly 15 years ago. When it was complete, the powerpoint was nearly 50 pages long. I covered everything I could think of.

When I entered the video chat, the leader was the only person there. The oddest thing happened next. She asked me to turn my camera off. I was taken aback. It felt like another opportunity to further de-humanize the situation, to make it Xs and Os. I agreed to turn it off, and all of the members had their's off as well. I would have liked to see the faces of the individuals who had my lively hood in their hands.

She asked if I would like her to screens-hare the 3 page synopsis that I sent her days before. I told her no, but would it be okay for me to share my screen? She asked what I would be sharing, and I informed her that I prepared a powerpoint. She said that would be fine, but asked why I didn't provide it beforehand. I told her that I had not finished it until earlier that morning, which was true.

The other members trickled into the meeting - silent, cameras off. 9 people in total. It felt like I was at an execution and couldn't see the people watching on the other side of the glass. My heart was beating out of my chest. Each one eventually introduced themselves and their role with the audit. Then the leader told me that I could begin. And so I did.

I planned a speech and memorized it beforehand. I built in pauses for the panel to respond. They did not. They did not say anything. I spoke for nearly 45 minutes straight without any response. I opened with the pictures of my family and clinic and humanized the situation as best I could. And then I attacked.

I attacked every single claim. I provided evidence, examples, precedence. I used semantics against them in any situation I could. I cited the NNA for signature issues. I showed them live sessions on our software so they could understand the complexity of a tech's job, and why they can't possibly write paragraph styled notes during a session. I showed them the update in the manual contradicting the RLTs responsibility. I referred to the AMA and how the 97153 code was defined, and how their expectations for that code directly violated it's core design. I completely talked out of my ass at times, not even knowing what words were coming out. I didn't make anything up, or fabricate or lie - I just pushed on every barrier. I questioned everything they did and to what purpose. I asked if they had any BCBAs or behavior experts on their audit team, since they questioned the validity of our notes. They did not. I asked if anyone could tell me what a mand or tact was - they could not. I asked how did they expect me to trust their judgement when they don't know basic ABA principals or operants. My emotions rode a wave of anxiety bordering panic attach to anger to determination as the meeting flowed forward.

At the very end, I returned to the humanity of the situation. I acknowledged that they may not see it my way, no matter how much evidence I presented. I asked them to remember that I am 1 person, and that I am a small, local organization - that I do not have investors or equity backing me. I reminded them that a recoupment of that amount would be crippling. In my eyes, I showed them that I did not commit fraud, or waste or abuse - the only thing that I was guilty of was not providing a perfect 97153 note.

I asked for leniency no matter what the results of my rebuttal were. I asked them to educate me and provide me with the tools to create the right documentation. I told them I would subject myself constant monitoring or auditing until it was perfect. But if they stuck to their plan to recoup 100% of the claims, it would devastate my company.

I finally stopped speaking, unaware of how much time elapsed. We sat in silence for nearly a minute. And then one of the panel members spoke, thanking me for the work that we do and recognizing my passion. Another woman seconded her sentiment. And then it was silent again.

The leader commended my passion and thanked me for the presentation. She then instructed one of the auditors to respond to some of my claims. Her and I had a back and forth professional conversation about signatures and then about narrative notes. She ultimately agreed that there was some ambiguity there and she would discuss the findings one we resubmitted. They gave me 30 days to respond and asked if I would like to keep the poweroint on record - which I said I did. My only regret from that meeting was not recording it for later review; I think it would have been very useful to hear their responses again.

The Re-Review: Last Call

I knew the weak spots in their arguments, and I knew how I wanted to attack. The next thing to do was locate, gather and organize the missing items. I wanted to be even more organized than before. I wanted to show them how I operate as a business owner. I wanted to be transparent, direct, and clear about everything.

• I bought 20 massive white binders, 3-4 inches.

• I created a template to include the claim, the problem, and my response in a condensed 1 page format with just facts.

• I printed out every billing log I had and attached it to the fact-sheet created above.

• For some claims, I printed graphs, raw data, and screen shots.

• For some claims, I printed payroll slips with hours, rosters, copies of registration certificates, email correspondence with Quality Monitoring Review auditors - anything to show that I am doing my best to be compliant.

• I printed and attached signature attestation forms for every X signature in which an employee was still working for me. For employees who were no longer there who signed X's I wrote a note saying that an attestation form could not be included because that employee no longer worked for us, and I included their termination date.

• I did this for every single claim, for every single client.

• Each client took a single binder and about a single ream of paper.

• I used an extra binder to print out my power point and other "commentary" to direct them to general repeating concepts, or explain how certain documents worked. I did this for every single argument, and some of this commentary went on for 10+ pages - especially when discussing the nuances of the 97153 code and the requirements of technicians writing paragraph styled session notes.

• I also found several things that I was absolutely in the wrong about: a session where our tech was not there and we billed the wrong date, sessions where we rounded the units incorrectly, sessions where we did not account for breaks that occurred, etc. There were several mistakes, but it was not an underlying or insidious issue. We owned up to the mistakes that we found during the review.

All in all, I sent out about 10 full binders of paperwork. Each section had a tab explaining what it was. Each section had a header page explaining what to expect. Each section had commentary about general aspects of my rebuttal. I left no stone unturned.

I mailed them prior to their due dates, got a tracking number and required signatures. I sent them priority and all together, mailing those boxes cost a couple hundred dollars. I emailed the tracking numbers to the people in charge, and then I waited.

The Final Response

In February of 2024, approximately 2 months later, I received an emailed response from one of the insurance companies. They reversed 98% of their findings based on my testimonial, the daily logs that were included, the commentary that I provided, and the signature attestations that we delivered. The recoupment dropped from $XX,XXX to $XXX.XX.

I was in awe. I read the letter several times to make sure that I was not mistaken. I won.

As of writing this blog, I have not heard from the other two, but I expect a response from one soon. The other is still in the first phase of the audit, and I likely will not hear from them for another 4 months. I will update this blog with those results when they come.

If you have received an SIU audit, these are my main takeaways from my own audits:

THIS IS SERIOUS

1. An SIU audit is extremely serious. Best case scenario: you pay back some overpayment costs (recoupment). Worst case scenario: you go to jail.

2. You do not need a lawyer, but getting a lawyer will be helpful and may save you if you are in very deep.

3. If you know that you are guilty of fraud, waste, or abuse, you will be in trouble because they are thorough. You are putting your life, your family and your practice at risk.
   

OVER SHARE

1. Some people say not give more than is asked and I thoroughly disagree. Send anything and everything that you find relevant to your case.

2. Provide every session note, every billing log, every daily log, permanent product, signature page, report - anything tied to that date and claim.

3. Organize everything by client, by date and by code as neatly as possible.

4. Turn everything in on time and remain in communication with your auditor.

5. Mail everything with a signature request, priority and with a tracking number. Share the tracking number with the auditor.

6. Keep a copy of everything that you have shared with them, either in paper or digital form.

DON'T ROLL OVER; FIGHT

1. If they respond by saying that you are in error and they want to recoup a large sum of money, do not roll over and give up.

2. If you think that you have made severe mistakes and you are in the wrong, do not wait to contact a lawyer. You will need real legal advice and assistance if that is the case.

3. Respond immediately to the results stating that you have received them and you are reviewing them. Then review them.

4. Compare your own records and validate or refute their claims.

5. Check what source they are using to come up with these rules or regulations and memorize the language.

6. If anything feels like a gray area or an area where you believe you are right and they are wrong, make a note why, put a star next to it, and move on to the next line. Do this for every single line.

7. Once you have gone through the entire spreadsheet and identifying where they are right and where they are wrong, contact them and ask if you can discuss the findings.

8. Video conference is better because you can provide a power point or share you screen to prove points. If over the phone, you will not be able to fight, but you can still make strong points.

9. Prepare your documentation again. For every area that you disagree, type up a response to their claim and back it up with additional evidence or your own dictation.

10. Admit to any wrong doing. If you've found areas that you have made mistakes, admit them. It shows that you are not attempting to deceive them, that you've made some isolated mistakes and you are owning up to them. They expect mistakes - it's literally hundreds of sessions.

    1. If a signature is missing, show them the staff member's payroll + your schedule for that day and have the staff member sign an affidavit that they worked with that client on that day. Even though this is months or years after the session, it doesn't hurt to try.

11. Hyper organize. Be respectful. Be honest. Over-communicate. Be timely. Don't forge. Don't edit. Don't embellish.

12. If the amount of money that they are attempting to recoup will severely negatively affect your company, explain why. Explain what the consequences could be if you were forced to pay that sum. Humanize yourself and your agency.

13. If you have made mistakes or aspects of your documentation was in the wrong, show them how you are fixing it for future sessions. Include a new template showing what your session note looks like now.

14. Encourage them to educate you. Ask for leniency. Ask for help. Show them your improvements.

15. Don't give up.

Full Legal Disclaimer: The information provided on this website does not, and is not intended to, constitute legal advice; instead, all information, content, and materials available on this site are for general informational purposes only. Information on this website may not constitute the most up-to-date legal or other information. This website contains links to other third-party websites. Such links are only for the convenience of the reader, user or browser.

Readers of this website should contact their attorney to obtain advice with respect to any particular legal matter. No reader, user, or browser of this site should act or refrain from acting on the basis of information on this site without first seeking legal advice from counsel in the relevant jurisdiction. Only your individual attorney can provide assurances that the information contained herein – and your interpretation of it – is applicable or appropriate to your particular situation. Use of, and access to, this website or any of the links or resources contained within the site do not create an attorney-client relationship between the reader, user, or browser and website authors, contributors, contributing law firms, or committee members and their respective employers.

The views expressed at, or through, this site are those of the individual authors writing in their individual capacities only. The content on this posting is provided "as is;" no representations are made that the content is error-free.