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.
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