Medical record requests by payors are commonplace for health care providers. Typically, these requests are received by a front desk employee who responds to the inquiry in short order.  Yet, not all requests should be treated the same.  When a request for documentation is propounded by the “Special Investigation Unit” (S.I.U.)  of an insurance company, special care should be exercised and provider involvement is required.

What is a S.I.U. anyway?  Over the past two decades, campaigns have intensified to curb fraud and abuse in health care.  On the government side, False Claims prosecutions have markedly increased and in the private sector, insurance companies have created specific departments to combat fraud.  The S.I.U. is a department within an insurance company with a targeted focus on recovering payments from medical providers that appear to be the product of fraud.  Individuals employed by a S.I.U. include former law enforcement personnel, claims adjusters and fraud analysts, among others, who receive specific training and credentialing in fraud detection.  These investigators utilize data analytics and other methods to flag providers for claims that fall outside of the “normal range” for the type of health care provider under review.

S.I.U. “audits” or requests for information about the practice should be taken seriously and taken to the top of your organization.   In many cases, special investigators receive incentives from the insurance company for recovering payments from providers.  They often attempt to “strong arm” a resolution by threatening a fraud claim, which in a number of states includes the prospect of treble (triple) damages, punitive damages, and attorneys’ fees.  In some cases, medical records produced by the provider (or the absence thereof) will assist the fraud allegation.  In others, the records will assist in supporting a defense to the same.

Here are 5 tips for your practice:

1. Instruct  staff that all audit requests should be forwarded to the owner of the practice and the provider whose records are being requested.
2. If the audit is deemed routine (not S.I.U. generated), instruct staff to make a copy of the records requested and the cover letter that attaches the records so that you can memorialize exactly what was provided and when.
3. If you receive a letter from the S.I.U., reach out to an attorney who has experience in dealing with the S.I.U. to assist you through the process.
4. If an investigator from the S.I.U. appears at your office, ask for a business card and do not let him/her disrupt patient care.  You can call them later (or your attorney can).
5. Do not provide access to your electronic records or files to anyone — including anyone employed by a payor.

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