P.R. Laws tit. 26, § 9085
(a) Claim auditors and provider audit coordinators shall have appropriate knowledge, experience, and expertise in the field of healthcare including, but not limited to, the following areas:
(1) Format and content of the health record as well as other forms of medical and clinical documentation;
(2) generally accepted auditing principles and practices as they apply to claim audits;
(3) billing claims forms in effect in the health insurance industry and billing procedures;
(4) all Commonwealth and federal regulations concerning the use, disclosure and confidentiality of patient records;
(5) specific critical care units, specialty area, and ancillary units involved in a particular audit, and
(6) Medical terminology and coding under updated codes, including ICD-10, CPT, and HCPCS, and as these may be reviewed and updated in the future.
(b) If a provider or health insurance organization or issuer finds that audit personnel do not meet these qualifications shall immediately contact the auditor’s firm or sponsoring party.
(c) Audit personnel shall conduct themselves in a professional manner and adhere to ethical standards and confidentiality requirements, and shall remain objective. They shall be required to completely document their findings and problems.
(d) All unsupported, unbilled or underbilled charges identified in the course of an audit shall be documented in the audit report by the auditor.
(e) Individual audit personnel shall not be placed in a situation through their remuneration, benefits, fees or other instructions that would call their findings into question. Compensation of audit personnel shall be structured so that it does not create incentives to produce questionable audit findings. Providers or health insurance organizations or issuers that encounter an individual who appears to have a conflict of interest shall contact the appropriate officers of the organization conducting the audit.
History —Aug. 29, 2011, No. 194, § 6.050, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 7, eff. 30 days after July 10, 2013.