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Audits and investigations in the healthcare industry are not that uncommon, but that doesn’t mean they aren’t confusing and stressful when they appear. As something that may happen to your medical practice at any time, an audit or investigation is a great source of stress for many physicians and doctors – especially when the audit or investigation is not understood.
If you want your audit or investigation to run smoothly and end in your favor, you will need to begin by learning exactly what an audit or investigation means, why you are being audited or investigated, and what you will need to do to maintain your reputation and your business.
All About Healthcare Audits
Having your medical practice audited is much more common than having your practice investigated. This is because the process of calling for an audit is easier than that of an investigation. An audit also has less severe consequences than an investigation.
In the healthcare industry, an audit just means an organization or contractor would like to take a closer look at a charge or bill that they have received. Audits typically begin with an insurance provider or patient feels that they are being overcharged for a service or treatment and they would like to better understand how your medical practice developed the amount that you charged.
When an audit is requested, it is not the same as being accused of fraud. You may be audited even if your expenses are legitimate and your services actually cost the amount that you charged. Being audited only means you need to provide additional information to support your bill or practices to explain away red flags that have been brought up.
Audits may also happen at random. While the majority of audits are the result of a red flag that needs to be proven or explained, it is not unheard of to have a random audit on a medical practice. These audits are primarily to hold medical practices responsible for the amount they are charging or buying while also developing an understanding of the purchasing practices of organizations.
If the auditors find information or evidence that you may have been committing fraud, your audit may turn into an investigation.
All About Healthcare Investigations
In a healthcare audit, the assumption if dishonesty or fraud is removed. When you are under audit, you simply need to explain your purchases and charges or show where that number was developed. But if you are under investigation, it means that there is reason to believe you have been acting dishonest or purposefully overcharging to receive additional compensation.
Investigations may begin if an audit finds something that could be considered fraud or if an employee of the medical practice sends in a tip that unethical behavior may be occurring. Insurance companies receiving suspicious billing patterns or patient complaints may also spark an investigation. But unlike a healthcare audit, a healthcare investigation will not happen at random.
In many ways, an investigation is much more serious than an audit. While an audit is only looking for deeper explanations, an investigation is looking for evidence of illegal activity.
Investigations may also lead to additional trials and court cases for individuals held responsible. If criminal acts are found, those who have engaged in fraud may risk losing their professional licenses and even face criminal prosecution.
Is a Chicago Healthcare Audits Investigations Lawyer Necessary?
Whether you’re going through an audit or an investigation, you will want to seriously consider contacting a Healthcare Audits Investigations Lawyer in Chicago.
During an audit, a Chicago Healthcare Audits Investigations Lawyer can help you understand why you are being audited and what red flags sparked the call for audit. An attorney can also help you comply with the rules of the audit and ensure it runs smoothly and efficiently, allowing you to return to business.
Because an investigation can have serious consequences, you will want to contact a Chicago Healthcare Audits Investigations Lawyer as soon as you are aware of the investigation. When working with your attorney, you can understand where the investigation came from, what they are looking for, and what potential consequences you or members of your team may be facing.