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What's the difference between an audit and an investigation?

As part of its review process, Magellan's Special Investigations Unit (SIU) may conduct a desk audit, an on-site audit, or request that a provider conduct a review of a subset of their records as a self-audit. Here's some helpful information regarding these types of audits and your role in each.

Audits

An audit is an objective and systematic assessment of how well a provider/program is performing and complying with applicable regulations. This is a routine process and can happen at any time.

• During a desk audit, you will receive a request via certified mail, fax and/or email for a list of members’ treatment records and other relevant documentation.
• An on-site audit can be announced or unannounced and can occur at any of your contracted service locations. Prior to an announced on-site audit, you’ll receive a notice that provides details and instructions about the audit. You won’t receive advance notice of an unannounced audit. SIU staff will provide you with proper identification as well as a written notice with further details and instructions.
  • During on-site audits, you’ll be expected to provide treatment records, personnel files, scheduling documentation, policies and procedures, or other documentation for review. If you maintain any of the information electronically, you must provide access or delegate a staff member to work with Magellan personnel to display the electronic records.
• We encourage you to conduct routine self-audits to assess and ensure internal compliance with policies, procedures and applicable regulations. A provider also may be required to complete a self-audit in response to findings from an investigation, audit, or data analysis activity, or in compliance with regulatory or contractual requirements.

Investigations

Magellan usually undertakes an investigation in response to reports of misconduct. It is a process of detailed examination to achieve certain objectives. An investigation may be conducted remotely or on site. You would receive an advance request for the relevant documentation.

Note that a lack of compliance with a request for records during any type of audit/investigation can result in:

• A Magellan Network representative contacting you.
• Retraction of payment for services not supported.
• Any overpayment identified is referred to Magellan's Cost Containment department for recovery by refund check or future claims retractions.
• Magellan completing required reporting to a customer oversight agency.
• Placement of a subset of, or all of, a provider’s claims on a pre-payment review.
• Termination from the Magellan network.

More information

• 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 an investigation.
• What to expect during a fraud, waste, abuse or overpayment audit or investigation.
• You can contact your Magellan 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 the SIU via email at SIU@MagellanHealth.com or via our hotline 1-800-755-0850 (you can remain anonymous).