You received a records request from Magellan's Special Investigations Unit (SIU), now what?
Magellan must implement and regularly conduct fraud, waste, abuse (FWA) and overpayment prevention activities to:
- Monitor and audit provider utilization and claims to detect FWA and overpayment.
- Investigate and pursue FWA, overpayment and other alleged illegal, unethical, or unprofessional conduct.
- Report suspected FWA, overpayment and related data to our customers and/or federal and state agencies, in compliance with applicable federal and state regulations and contractual obligations.
SIU may choose to conduct a desk audit during an audit or investigation. If you receive a request for treatment records from the SIU, here are some helpful reminders to help facilitate the process:
- During a desk audit, you will receive a request for member treatment records, other relevant documentation and possibly an "Audit Questionnaire" or "Electronic Health Records Questionnaire" via certified mail, fax and/or email.
- It is important to respond to SIU's requests within the timeframe specified. In the initial records request letter, SIU will provide details on how to transmit the documentation. If you have questions, reach out to the SIU point of contact listed on the request.
- SIU may also review your submitted claims, interview you and/or your staff, conduct relevant background checks and interview members.
Lack of compliance with a request for records may result in:
- A Magellan Network representative contacting you.
- Retraction of payment for services not supported.
- Any overpayment identified will be referred to Magellan's Cost Containment department for recovery by refund check or future claims retractions in compliance with contractual and regulatory requirements.
- Required reporting to a customer oversight agency.
- Placement on a pre-payment review.
- Termination from the Magellan network.
- Review Magellan's policy on audits and investigations in Section 4 of Magellan's National Provider Network Handbook (PDF), including:
- Cooperating with Magellan's audits and investigations.
- The difference between an audit and investigation.
- What to expect during a FWA or overpayment audit or investigation.
- Contact your Network representative with questions regarding your contract and obligations to provide medical records for review.
- If you have additional questions regarding our audit/investigation processes, contact SIU via email at SIU@MagellanHealth.com or via our hotline at 1-800-755-0850 (you may remain anonymous).