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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.
– Fines of at least $5,000 per count
– Restitution of all monies stolen in full
– Prison time of no more than 5 years per count
– License suspension
– License revocation
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.