BCBSAZ/Advize audit UPDATE
A word of caution to clinicians regarding recent BCBSAZ audits and repayment findings:
I recently reviewed and am posting (with permission) audit findings shared by a colleague from BCBSAZ that should concern any therapist, supervisor, group practice owner, or associate-level clinician providing behavioral health services. For history, I am also under the same type of audit and received a clawback letter of over $551,000 by BCBSAZ. I've personally retained an attorney and submitted a complaint with our state insurance commissioner. A third clinician reached out to me recently sharing similar audit results from BCBSAZ to the tune of over $131,000.
The audit relied heavily on broad references to:
- CMS “incident to” billing concepts
- BCBSAZ provider manual language
- Telehealth documentation requirements
- Supervision expectations
- Medical record timing/signature standards
The problem is not simply that standards exist. The problem is the extraordinary specificity of the interpretations being applied retroactively during audits... often in ways that are not clearly articulated in the provider manual itself and that many otherwise ethical, competent clinicians would likely fail.
One particularly concerning theme is that many requirements cited in the audit findings are either only vaguely described in the provider manual, or imported from broader CMS guidance without operational clarity for behavioral health clinicians.
In practice, this creates a situation where clinicians may believe they are compliant because they are acting ethically, documenting appropriately, and following common industry standards, while auditors later apply highly technical interpretations that were never clearly operationalized beforehand.
This has major implications for all of us and is a warning that many clinicians may unknowingly be exposed.
Be advised: there are now THREE of us who have received extrapolated three year clawbacks of six figure amounts in Arizona. At least two other clinicians are still pending their audit results.