P.R. Laws tit. 26, § 9088
(a) In order to have a fair, efficient, and effective audit process, providers and health insurance organization or issuer’ [sic] auditors shall adhere to the following requirements:
(1) Whatever the original intended purpose of the claim audit, all parties shall agree to recognize, record or present any identified unsupported, unbilled or underbilled charges discovered by the audit parties;
(2) the scheduling of an audit shall not preclude late billing;
(3) the parties involved in the audit shall mutually agree to set a time frame for the resolution of any discrepancies, questions or errors that surface in the audit;
(4) an exit conference and a written report shall be part of each audit. If the provider waives the exit conference, the auditor shall note that action in the written report. The specific content of the final report shall be restricted to those parties involved in the audit;
(5) the provider shall be afforded forty (40) calendar days to contest all findings, after which the audit shall be considered final;
(6) once both parties agree to the audit findings, audit results are final;
(7) all personnel involved shall maintain a professional, courteous manner and resolve all misunderstandings amicably, and
(8) if the auditor notes ongoing problems either with the billing or documentation process and it cannot be corrected as part of the exit process, the management of the provider and health insurance organization or issuer shall be contacted to apprise them of the situation. The provider and health insurance organization or issuer shall take appropriate steps to resolve the identified problem. Parties to an audit shall eliminate ongoing problems or questions whenever possible as part of the audit process.
History —Aug. 29, 2011, No. 194, § 6.080, eff. 180 days after Aug. 29, 2011; July 10, 2013, No. 55, § 10, eff. 30 days after July 10, 2013.