Navigating the Audit Process

When an insurance company decides to undertake an audit or in-depth investigation, they will often write to you or your clinic to request information or schedule a site visit. In some cases, insurance company employees may show up unannounced and ask to review documents. In such instances, it’s reasonable for you to ask that they book an appointment to return another day. This will enable you to ensure you and your staff have adequate time to facilitate their request(s).

When an insurer writes to inform of an in-depth investigation, they will provide a timeline in which they expect to receive the requested information. It’s in your best interest to comply with audits or in-depth investigations in a timely and transparent fashion.

According to the CLHIA, failure to respond to a request to provide information for audit purposes may result in:

  • Delays in the reimbursement of the claims being audited
  • Delays in the processing and payment of future claims
  • Requests for additional, detailed documentation to support future claims
  • Refusal to reimburse expenses claimed¹

There may be instances where you require more time to respond, for example, if you are out of town on vacation or for work-related travel. If this is the case, contact the insurer as soon as possible to explain your situation and make alternate arrangements.