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If you’re healthcare practice is being audited by private insurers, or medicare / medicaid contractors, then we encourage you to contact us. The aim of such audits is to determine if there has been overpayment for services rendered. Healthcare providers can be selected for auditing based on red flags, or can be selected on a random basis. In some cases, a determination of overpayment may be made – which is not the same as fraud. In situations like this, it’s important to speak to a competent attorney who can help advise you on your rights.
It is common for auditors to find overpayment being made – which is different from dishonesty/violation of regulations. Mistakes, clerical errors, or even a difference of opinion – can lead an auditor to make a finding of overpayment and force the provider to repay the amount due.
This is a very long process, and one in which you’ll want our help. An auditor will review all the claims submitted by the provider, going back several years. This review done without notice to the provider. The first time you learn you’re being audited – may be when there is a determination of overpayment. This will result in formal notice – stating the determination, and requesting additional documentation and information. It’s crucial you take action as soon as possible. If you delay, this may increase the amount for which you’re liable and could jeopardize your ability to present evidence at a later time. We highly recommend you speak to our Austin healthcare audit lawyers, who can help formulate the legally correct response. Volunteering excess information could harm you legally. Without an attorney, any communication you give will be considered evidence throughout the appeals process – as well as the litigation process. Be aware of the fact the goal of any healthcare auditor is to recoup as much money as possible. While some audits are random – most are triggered by red flags. One of those flags is a high service volume. This can cause the insurer to assume services are being over-utilized. Repeat usage of the same CPT code for patients can trigger additional scrutiny. Insurers assume that patient encounters will have varying outcomes – thus assuming different codes should be used. High volume of code modifiers indicating that additional services beyond the scope of the patient’s condition are also a prompt. Bottom line, insurers have assumptions about services – and how they are provided – if you don’t fall into that profile – you risk possible investigation and audit. Any deviation can put you at risk.
Investigations are done by the government law enforcement agencies, and are done due to suspicion of illegal activities. Investigations happen due to tip-offs from patients, employees, or due to an audit. Many government agencies have methods of detecting fraud, including collecting and analyzing data from claims to reveal a pattern of fraud. As soon you are you’re aware you’re being investigated – we encourage you to speak to our attorneys. Never speak to anyone without having an attorney on your side.
The investigation conducted can impact you on many levels. At Raiser & Kenniff, PC, we’ve successfully represented healthcare providers and can help you.