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Todd Spodek (Managing Partner)

Mr. Spodek decided early on in his life to focus his education and experience on trial work. Todd Spodek attended Northeastern University in Boston, MA and majored in criminal justice. This background provided an indispensable tool in the representation of criminal defendants in grand jury investigations, pre-trial hearings, trial, appeals and navigating the corrections process.…

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philadelphia healthcare audits investigations lawyers

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.

Healthcare Audits and Investigations Lawyers

If you are a health care provider, then it’s essential you take proactive steps to keep your financial records as accurate as possible so that you don’t need to worry about the outcome of an audit. Staying safe means always using caution when you bill an insurance company so that you don’t get accused of overcharging. Getting audited does not always mean you will face negative consequences, but it can still be a stressful experience. Staying updated on related laws can go a long way to help keep you and your practice safe, but you cannot eliminate the odds of being audited entirely. It’s important you learn about the auditing process before you find yourself in the middle of it. Learning how to respond to an audit can be the difference between having the charges dropped and facing time in prison.

Audit Process

In some cases, insurance companies randomly adult health care providers so that they can spot instances of overpayment that might not be apparent right away, and you can do nothing to prevent this from happening. You will also be audited if you set off any red flags during the course of your job. For example, if an insurance company feels as though you have been overcharging for a service, they will take action to determine whether the related claims are legitimate.

Auditors will pay close attention to detail so that they can determine the accuracy of each record. During this time, they will check each claim to ensure it matches a corresponding patient record so that they can verify its legitimacy. If they find any discrepancies, their next step is to determine whether you made a mistake or tried to commit fraud.


If a health care auditor determines you have overcharged the insurance company on purpose, then they will likely turn the situation over to a federal law enforcement agency. Rather than searching for mistakes, federal agents will now be looking for evidence of fraud and other criminal activity. If the federal agents do not find enough evidence to use against you, then they will drop the case, and you will not face charges. However, if they determine sufficient evidence is present, then you will be subject to prosecution and civil litigation. No matter the outcome, if an investigation gets this far, your career will be placed in jeopardy.

Responding to an Audit

When a health care auditor first decides to check your records, you are not likely to be notified. They don’t want you to take steps to protect yourself until they have enough evidence to use against you. It’s important you remember that evidence of an overcharge does not always result in criminal charges. But if the auditors believe you made a mistake, they will still expect you to pay back the amount you owe. Either way, they plan to take action by the time you realize they are auditing you. So, it’s vital you contact a lawyer right away so that you can have the best possible odds of winning your case. If an auditor tries to ask you questions, do not respond until you have spoken to a legal adviser. Otherwise, anything you say will likely be used as evidence against you, damaging the durability of your case.

Final Thoughts

Although being audited is a stressful experience, you do not need to feel powerless to protect yourself. The first step you must take to stay safe is to ensure all of your records are accurate. It’s also vital you use caution when entering a patient’s billing information so that your motives don’t get called into question by investigators. By the time an insurance company notifies you that an audit has taken place, the odds are already stacked against you. At best, you will be forced to repay any questionable claims. In the worst case, you will be put on trial for fraud, and you could find yourself in prison if your case goes downhill. If you want to stay safe from legal problems, then you must contact a lawyer the second you realize you are being audited or investigated so that you can build a strong defense.

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