Med Center faced with second audit

Pennsylvania Blue Shield is currently conducting a private audit of the billing practices of the 600 physicians of the Clinical Practices of the University of Pennsylvania. This review will examine a sampling of claims related to the services in question, according to Douglas Smith, vice president of Corporate Affairs at Pennsylvania Blue Shield. Smith said the audit is separate from the one conducted last month by federal Medicare officials. As of yesterday afternoon, CPUP had not yet been contacted by Blue Shield concerning the review, according to Lori Doyle, University of Pennsylvania Health System spokesperson. In the original Medicare audit last month, the Hospital of the University of Pennsylvania agreed to pay $30 million to the federal government in order to settle Medicare claims that Medical Center physicians overbilled patients. Pennsylvania Blue Shield played a role in the first review because, as a federal Medicare carrier, the company serves as a "contractor" to the federal government. "Really what you have is a private health insurance company housing a federal insurance program," explained Smith. He said that this audit will only be investigating the service bills relevant to the Blue Shield program private insurance company. The previous audit dealt only with federal Medicare claims. The only overlapping information pertains to records from Medigap, an insurance program which is part federal and part private. Smith added that the second, private audit was not spurred by the federal investigation. "Basically, Blue Shield was aware of the potential for problems but was also aware of the federal audits going on, so we stepped back until they were finished," Smith explained. He said Blue Shield had received a tip from an anonymous source confirming their suspicions of existing problems. He added that this is frequently the reason that the company undertakes reviews. Last week, John Eisenberg, former chief of General Internal Medicine at Penn, speculated that the tip came from a disgruntled patient. But Smith said this was probably not the case. "Frequently, someone will look at their statement and see something and say, 'Hmmm, that doesn't look right,' and they'll send it to us," he said. Smith said such discrepancies can range from a slight overbilling to a charge from a doctor patients have never visited. He added that when Blue Shield receives a tip from a source, they can instantly check their data bases and try to reconcile the discrepancies. Then the company can choose either to look further into the situation or assume that it is an isolated incident, he said. "Some things are obviously worth looking into," Smith said. "You can only have your appendix out once." CPUP officials declined to comment on the pending Blue Shield review.