A healthcare audit is a serious matter that can be a very stressful time when not dealt with by an experienced attorney. A healthcare audit is typically initiated by an insurance provider or a third-party. The audit is to review records that may be in question regarding payments made to the healthcare provider. An audit letter can be delivered in-person or through the mail. It’s a matter that requires immediate action and retaining an attorney as quickly as possible is always advised. This informative article will review some of the items regarding the auditing process and the effects it can have on a healthcare provider.
Healthcare Audits Explained
A healthcare audit can be initiated for one of many reasons. Often, the insurer that’s questioning claims will notice a pattern of unusual conduct such as a sudden increase in the number of claims being filed without any logical justification such as a public health matter. Whistleblower claims are also common and are usually initiated by a disgruntled former employee or someone that stands to benefit from the negative action. Current employees that are dishonest may also file false claims in order to embezzle. This is only a very small sampling of the reasons that an audit can be performed outside of the scope of spot checks and routine audits based on your contract.
Since Medicare and Medicaid are under strict scrutiny by the government and are especially susceptible to fraudulent claims, these are among the most common audits. Third parties that are contracted by insurers are often used to review over and underpayments, suspected fraud, and areas of medicine that are especially vulnerable to fraudulent claims.
How an Audit Works
Upon receipt of the letter advising you of an audit, you’ll be required to respond within a specific period. Ignoring the letter will only make matters worse and can subject you to significant fines and penalties. At this point, you’ll want to get in touch with a highly skilled healthcare attorney. It’s inadvisable to file your own response without legal representation. Typically, the attorney will ask the reasoning behind the audit to determine if it’s valid and necessary. They’ll file a response on your behalf. If all goes well, you might be able to avoid an audit altogether. If the insurer or contracted auditor still has a valid reason to proceed, a game plan will be put into action. Recordkeeping practices will be scrutinized during this time, so it’s important that everyone knows their job and how to keep accurate and thorough records. Should the audit go well, you’ll be finished with it. If not, you’ll most likely move towards an appeal or a hearing.
The Effects of a Negative Audit Result
Without the assistance of an attorney, an audit can go very wrong. You’ll be risking your ability to take certain insurance plans and can even be charged with insurance fraud on a local and federal level. Penalties and fines are typically hefty with these cases, so it’s important that you involve an attorney at the earliest point possible. With civil and criminal penalties at stake, this isn’t a matter that you’d want to take into your own hands, even if an expert on healthcare fraud and abuse. Unfortunately, the state and federal courts aren’t sympathetic to those who don’t want to hire an attorney. If the result remains negative after the case is resolved, an attorney would most likely be able to significantly have the fines, penalties, and any criminal ramifications reduced significantly. Our team will be happy to guide you through the healthcare auditing process and develop a winning strategy for you. Get in touch with us to schedule your appointment, today!