Federal healthcare entities overpay insurance claims by billions every year, and no medical facility is immune to receiving such overpayments. In an effort to reduce the number of overpayments issued to medical facilities on an annual basis, each state in accordance with the federal government issues healthcare audits and investigations on occasion. These audits can even be initiated by a private healthcare provided such as insurance company if they suspect overpayments are being made.
How is an Audit Determined?
Most every medical facility in Houston will undergo at least one healthcare audit or investigation at some point in their existence. Some occur because certain red flags are raised when payments are issued, and others are completely random. When a medical facility is made aware of an audit or investigation within their office, it’s shocking. The good news is it’s not always a bad thing. Sometimes overpayments are made on accident, billed on accident, and occur through no real malicious intent. When this happens, it’s considered a mistake. Facing penalties is reserved only for those found guilty of healthcare fraud. If an office or doctor is found guilty of healthcare fraud, they could face federal punishment.
How an Audit Works
Healthcare audits and investigations are time-consuming and stressful. When a medical facility is notified of an audit or investigation, it’s in their best interest to call an attorney who specializes in healthcare audits and investigation. The process requires providing specific information and paperwork from files years old, and it takes a lot of a doctor’s time away from their patients. When an attorney is utilized, doctors have more time to spend with their patients while their attorneys handle the legal aspect of audits and investigations.
Audits and investigations might be ongoing for months without you ever being made aware. It’s not until an auditor determines in their own files that an overpayment was issued you are notified. It’s at this point you are required to submit documentation, files, and proof that you didn’t maliciously overcharge or fraudulently bill the insurance provider.
Red flags include:
– Use of the same code for multiple patients on a regular basis
– Duplicate billing
– Overcharging for specific procedures
– Performing multiple procedures on many patients deemed unnecessary
Auditors want to make sure they didn’t overpay through a mistake of their own or your office. It happens all the time a patient code is entered incorrectly and someone is charged for something they didn’t have done in lieu of something they did have done. Mistakes happen, and most auditors are aware of this.
How an Investigation Works
If your medical facility is under investigation, it’s a different situation all together. These are performed at a federal level, which means your office is being watched for suspicious activity. Fraud is the biggest criminal issue at hand here, and there are many red flags. The vast majority of red flags here include multiple reporting errors in the billing department, patients who are being billed for the same procedure as dozens of other patients, and more. Investigations usually occur when the auditor of an office determines there is fraud going on.
If fraud is proven, doctors will lose their licenses. They are then responsible for paying fines in the thousands of dollars for each count they are charged with, as well as spending up to five years in prison for each count they’re found guilty of committing. Federal law requires all medical professionals are to pay back all the money they overcharged or essential stole from insurance carriers, and they will live the rest of their lives with a criminal record. Doctors are not permitted to practice medicine with a criminal record, so their entire future is in jeopardy.
Call an attorney if your office is being audited or investigated. Attorneys help with the process, provide pertinent information to their clients, and they work to ensure clients get the best possible outcome after any audit or investigation is completed.
Spodek Law Group have offered me excellent support and advice thru a very difficult time. I feel I've dealt with someone who truly cares and wants the best outcome for you and yours. I'm extremely grateful for all the help Spodek Law Group has offered me. I can't recommend them enough.
Spodek Law Group was incredibly professional and has given me the best advice I could wish for. They had been helpful and empathetic to my stressful situation. Would highly recommend Spodek Law Group to anyone I meet.
Best service I ever had. Todd is absolutely class personified. You are in the safest hands with spodek. They have their clients interest in mind.
We provide superior service, excellent results, at a level superior to other criminal defense law firms. Regardless of where your case is, nationwide, we can help you.
Healthcare regulatory oversight action is an area of government operation that has increased significantly over the past five years with the full implementation of the Affordable Care Act. The Department for Human and Health Services has performed regular audits, but all healthcare providers have also been focusing on internal self-audits to ensure their billing codes and procedures are accurate and current. Government officials have actually decided, along with the court system, that regular audits within any healthcare provider system can be acceptable when problems are identified and the provider responds within the 60 day time frame for financial restitution set forth in the law. The system still has vulnerabilities regarding systemic potential for fraudulent billing, and many codes showing a major increase in the past few years have also included upper level codes that result in higher payment to the provider. Of course, when the FCA sends out a subpoena for a formal audit the situations get more serious. This is when it is time to retain an experienced Philadelphia healthcare lawyer who understands what the government may want to clarify or has possibly already found.
Civil and Criminal Possibilities
General audits begin as civil legal situations that are normally primarily focused on potential billing problems. Human error can easily be a component of any problems found, and even continual systemic billing errors can exist. Billing codes change regularly, which is also a central reason the DHHS wants all healthcare providers to test their billing system regularly. Problems usually start when intent to defraud can be found or an informant supplies information to the government regulatory agency regarding management instructions that could potentially be illegal. These are effectively charged under the False Claims Act and can result in significant fines in even civil situations, and can include jail sentences when the case is egregious. The False Claims Act gives the informant, termed a relator in legal language, the legal standing to sue and share a percentage of any proceeds that are confiscated or returned to the government. Even when a case is not prosecuted criminally, a healthcare provider could be assessed a damaging civil fine as well as being required to pay restitution.
Defending Your Business
Healthcare audits are basically digital forensics investigations of any subpoenaed provider. Serious cases of fraud could easily result in a provider being closed, which can be especially impactful to private practices. Any existing record of regular billing system checks can be used as positive documentation supporting claims that any problems are the result of errors or communication breakdown between the regulatory agencies and the providers themselves. Your Philadelphia healthcare lawyer can evaluate any article of evidence and build a case for human error at the worst without having a civil inspection and audit ascend to a potential criminal issue.
Why Former Prosecutors are Most Effective
Many large law firms that focus on healthcare representation have a cookie cutter approach to defending against healthcare audit investigations. That is not always true of private practice attorneys who are former prosecutorsthat understand what the regulatory agencies must find in order to justify criminal charges. The process of providing medical billing is a massive informational transfer and the potential for human error is always present. This condition is why self-auditing can be so effective. But, when the government comes calling, your professional legal counsel will automatically know what they are pursuing in terms of possible criminal intent. The former official professional status of a defending attorney can serve as an indication that the healthcare provider in question is serious about repairing any problem as well. Even a routine system check can present trouble when discrepancies are found, and having your own legal team throughout the inspection can be vital to limiting financial damage and potentially passing the audit. Having a reputable attorney is not just an investment in the sustainability of your business. It is an investment in your personal future as well in many instances.
555 W 5th St 35th floor, Los Angeles, CA 90013
35-37 36th St, 2nd Floor Astoria, NY 11106
85 Broad St 30th Floor, New York, NY 10004
195 Montague St., 14th Floor, Brooklyn, NY 11201